adv. princip: Laparoscopy

Question 1

what procedures are usually done laparoscopically?

Answer 1

gynecological
general surgery (hernias, choles)
urological surgery
VATS
DaVinci robotic surgery

Question 2

what is Pneumoperitonium

Answer 2

insufflation of peritoneum with CO2 in order to visualize the abdominal organs with laparoscope

Question 3

what are the 2 techniques for accessing the peritonium?

Answer 3

open and closed

Question 4

what is a closed technique?

what are risks and benefits?

Answer 4

closed: a spring loaded needle is used to pierce the abdomen wall in the thinnest point (infra-umbillical region), trocar is then inserted
- high risk organ injury, vascular injury (vena cava, aorta, iliac arteries, veins, bladder, bowel, and uterus puncture(d/t blind stick))
- h/r gas emboli, migration of gas

Question 5

what is the open technique?

what is the benefit of this technique?

Answer 5

open: an incision is made in the infra-umbillical region and the trocar is inserted,
-less risk of vascular injury
-faster insufflation=shorter surgical time
h/r-vascular injury, organ injury, gas emboli, migration of gas

Question 6

what are contraindications to laparoscopic surgery
absolute:
relative:

Answer 6

absolute contraindications to laparoscopy:
-a. bowel obstruction -b. peritonitis -c. intra peritoneal hemorrhage
-d.cardiac disease
relative contraindications:
-e. pregnancy -f. increased ICP

Question 7

1. what sometimes occurs to end tidal CO2 with insufflation

2. how is it remedied?

Answer 7

1. end tidal co2 may go up due to absorption of CO2

2. increase vT will blow off the CO2

Question 8

what pre-existing conditions increase risk of complications of pheumoperitonium?

Answer 8

1. obesity
2. previous surgeries
3. adhesions
4. masses

Question 9

name some potential complications of pneumoperitonium:

Answer 9

1. vessel damage (aorta, vena cave, renal arteries, iliac arteries)
2. bladder perforation
3. bowel perforation
4. uterus perforation
5. gas emboli or migration of gas to closed (extra peritoneal)spaces

Question 10

1. what is mortality on major vascular injuries from Laparoscopic procedures?
2. what is the treatment

Answer 10

1.15%

2. laparotomy to control hemorrhage (vessels are retro-peritoneal)
   (if aorta is perforated, must cross clamp

Question 11

1. what must the patient do before heading to the OR?

2. what can we place (GI/GU) to prevent organ injuries?

Answer 11

1. void (you don’t want a full bladder during laparoscopic procedures).
2. also insertion of foley or ng tube is good to prevent gastric and bladder laceration.

Question 12

1. what is a gas embolism
2. what are the s/s
3. what is the TX

Answer 12

1. the varess needle inadvertently injects co2 into an intra abdominal vessel (rare but 28% mortality rate)
2. s/s of gas emboli are hypotension, bradycardia, drop in o2 sat, increased then decreased ETCo2
3. treatment: stop insufflation, release pneumoperitonium, Durant’s manuver (left lateral steep trendelenberg), aspirate air via central line (if present), fluids.

Question 13

1. what is another pulmonary risk of laparoscopic procedures?
2. who is high risk for this?
3. where are the weak points where this will occur?
4. what are the s/s?
5. tx?

Answer 13

1. pneumothorax
2. persons having laparoscopy for reflux, (nissan fundoplication)
3. weak points are esophageal and aortic hiatus
4. Decreased lung compliance, SQ emphysema, hypotension, hypoxia
5. tx=chest tube

Question 14

what are the physiologic effects of pneumoperitonium (insufflation of peritonium)?

Answer 14

1. direct mechanical effects- (comression of cardiovascular system and lungs).
2. neurohumoral responses (release of catacholamines d/t decreased svr)
3. effects of absorbed CO2

Question 15

a.what are the direct mechanical effects of Pneumoperitonium on CV system

Answer 15

a. 1. Increased SVR from compression of abdominal arteries
2. increased venous return
3. decreased stroke volume d/t increased intra ab. pressure
4. decreased cardiac output d/t increased intra ab. pressure
5. increased arterial blood pressure d/t increased afterload
6. bradycardia from stretch of vagus nerve (parasympathetic stim)

Question 16

what are the Humoral (neurohumoral) and rhythmicity effects of pneumoperitonium?

Answer 16

1.increased SVR leads to sympathetic stimulation which releases catecholamines (rennin, vasopressin, norepi, epi, dopa &cortisol)
also,
2. hypercapnia from CO2 insufflation leads to decreased myocardial contractility and decreased antiarhythmic threshold
-vagus stretch= bradycardia

Question 17

how long do direct mechanical cardiac and humoral effects of pneumoperitonium last?

Answer 17

30 minutes after deflation of peritonium

Question 18

I. what are the gas related pulmonary effects of Pneumoperitonium?
II. what are some of the secondary effects (vascular/ rhythmicity)?

Answer 18

1. Increased arterial CO2
2. Increased end tidal CO2 (level off post 40 min, (may be higher if insuflation is extraperitoneal))
3. ETco2 of >50 (to 70) is dangerous d/t fact it can cause: a)increased cerebral blood flow
   b) periphrial vasodilation
   c) pulmonary vasoconstriction
   d) cardiac dysrhythmias

Question 19

what is the treatment for elevated CO2 with pneumoperitonium?

Answer 19

1. increase PIP
2. decrease I:E ratio to 1:1 (increases rate)
3. pressure control vent
4. invorporate “sigh” or increase Vt

Question 20

what are the physical pulmonary effects of pneumoperitonium and exogenous CO2?

Answer 20

1. displacement of diaphragm cephalad
2. decreased FRC
3. decreased VC
4. increased dead space ventilation
5. decreased pulmonary compliance/ increased insp pressure

Question 21

what are the effects of trendelenberg and reverse trendelenberg on the pulmonary system

Answer 21

1.Trendelenberg- supine with feet higher than head:
s/e-decreased pulmonary compliance, increased venous return
2.Reverse Trendelenberg-supine with head higher than feet:
s/e- inproved diagram function, risk of right mainstem intubation, endotracheal tube can creep out

Question 22

what are the renal effects of pneumoperitonium?

Answer 22

1. compression of kidneys
2. compression of IVC
3. increased levels of ADH/ vasopressin
4. decreased urine output

Question 23

what anesthesia method would be most useful with laparoscopic surgery?

Answer 23

General anesthesia - may be LMA or ETtube: local or regional is an option but has limited usefulness

Question 24

post op nausea and vomiting:

1. what is the incidence?
2. how should it be treated (pre & post op)

Answer 24

1. post op NV has a 60% incidence
2. a) dramamine po -pre op
   b) decadron 4-8 mg prior to incision
   c) zofran 4 mg (5HT3) 30 min prior to closing

Question 25

what 3 conditions shoud you treat carefully in terms of laparoscopic surgery (in regards to fluids and gas machine settings)?

Answer 25

1. Cardiac Disease 2. COPD 3. Obese (d/t closing volumes)

Question 26

explain the concept of closing volumes:

Answer 26

Obese persons lungs operate at just above closing volume on a daily basis (closing volume is a volume of air moving that is less than the volume needed to keep broncioles etc. open) in trendellenberg, the volumes decrease and reach closing volumes d/t increased pressure of abdomen on lungs.

Question 27

what is the best mode of induction for laparoscopic procedures

Answer 27

1. induce with propofol (decreases n/v) 2. NDMR for intubation 3. LMA (pro seal)-remember rule of 15 (no more than 15 cmH20 for no more than 15 minutes)

Question 28

what must you do extra for robotic cases? | why?

Answer 28

1. 2 ivs in bilat arms with extension tubing, 2 bp cuffs, | 2. the arms will be tucked and you wont be able to move patient once robot is docked.

Question 29

1. Steep trendelenberg is used for what procedures? | 2. What are nursing implications?

Answer 29

1. Robotic GYN, prostate procedures 2. a. Increased inspiratory pressures( may need pressure control) b. pad shoulders and arms secure patient to OR table, gel pad under patient (especially for VERY steep)

Question 30

For what procedures would Reverse Trendelenberg be used?

Answer 30

Cholecystectomy, nissan fundoplication

Question 31

What robot procedures should we judicious with fluids in?

Answer 31

1. Urology (dont want a full bladder) | 2. Steep trendelenburg (if face gets swollen...airway is swollen)

Question 32

Monitors for laporoscopic cases:

Answer 32

1. Ogt for gastric decompression 2. ETCO2 3. Train of 4 on face 4. Others based on comorbidities

Question 33

with the davincci robot, what else on the patient would you pad (besides the obvios-shouldres, elbows, ankles...)?

Answer 33

place a pad or foam over the patient's chest and face

Question 34

1. what is a complication of big bowel surgery that you should account for (patient will be ___ from pre op ___ ____) 2. this makes them at risk for what? 3. what should you do and use caution in what patients?

Answer 34

1. dehydrated from pre op bowel prep 2. they will be at risk for hypotension with positon change and ION 3. replace fluids as calculated being careful in cardiac and steep trendelenberg

Question 35

1. what is ION? 2. who is at risk for ION ? 3. which position puts patients at highest risk? 4. what duration of surgery puts patients at highest risk?

Answer 35

1. ION (ischemic optic neuropathy) 2. high risk for ION: persons with diabetes, low bp, dehydrated, cardiac issues, ? men, 3. steep trendelenberg position is highest risk for ION 4. surgeries longer than 4 hours are high risk for ION

Question 36

How does length of surgery change your induction plan?

Answer 36

You should adjust your MR according to length of surgery.