Anesthesia for Laparoscopic and Robotic Surgery (Part 2) Flashcards by Collin Morris

Cholecystectomy Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB
Positioning: Reverse Trendelenburg, L-tilt
Procedure: can be done traditionally or robotic-assisted

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Appendectomy Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB
Positioning: Trendelenbrug, L-tilt, L arm tucked at side
Procedure: Traditional or robotic-assisted

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Nissen Fundoplication Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB RSI
Positioning: Supine
Procedure: Traditional or robotic-assisted

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Nissen Fundoplication Special Considerations

-High aspiration risk
-RSI + PONV prophylaxis!
-NOTHING IN ESOPHAGUS!

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Adrenalectomy Anesthesia, Positioning, Surgery

-Usually done for pheochromocytoma
Anesthesia: GETA with NMB
Positioning: Lateral position
Procedure: Traditional or robotic-assisted

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Adrenalectomy Special Considerations

-Remember alpha before beta blockade (alpha block 10-14 days preoperatively)
-Major hemodynamic changes expected –> large bore IVs, adequate hydration, ABP monitoring, take BP meds DOS
-Use of multimodal pain management and erector spinae block

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Pheochromocytoma Classic Triad

-Headache
-Diaphoresis
-Tachycardia
think too much coffee even though we never have enough

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Diagnosis testing for pheo:

-Plasma free and urinary fractionated metanephrines
-CT abdomen

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Hysterectomy Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB
TAP block for pain management
Positioning: Steep trendelenburg, low lithotomy, arms tucked to side
Procedure: Traditional, Robotic-assisted, or Mix
Use of dye

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Gastric Bypass Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB
Positioning: Steep reverse trendelenburg
Procedure: Traditional or robotic-assisted
Nothing in esophagus

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Adjustable Gastric Band
Purpose and benefits?

-Reduces/limits food intake
-Avoids permanent alteration of anatomy and has low mortality + low re-operation rates
*Done laparoscopically to reduce morbidity, mortality, and hospital costs

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Sleeve Gastrectomy
Purpose and risks

-Permenantly removes portion of stomach
-Risks of infection, leak at staple line, malnutrition
-Can be negated by overeating

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Roux-en-Y Gastric Bypass
Purpose and risks

-Small gastric pouch connects to jejunum to change GI hormones
-Risk of vitamin deficiency, malnutrition, perforation, staple line failure, dumping syndrome

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We don’t feel great about our patients breathing, they are still super somnolent after the procedure. What do we do?
Obesity Review

Leave em intubated

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Benefits of minimally invasive robotic surgery

-Improved patient outcomes
-Greater precision
-Reduced blood loss and postoperative pain
-Shorter LOS
-Faster recovery

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An important advantage of robotic technology is the incorporation of ___-____ imaging giving better depth perception.

Three-dimensional
-Improves ergonomics, dexterity

Anesthesia Implications for robotic-assisted surgeries

-Longer operation times
-Harder to access pt
-Physiological changes due to positioning for robot
-Physiological changes due to pneumoperitoneum use
-Risk of POVL
-New ERAS protocols

Why is adequate preparation of the pt for robotic surgery so essential?

We often cannot access the pt as we could normally due to the robot.
-Secured airway, good IVs, monitoring devices secured

____ ____ is a commonly used position for robotic procedures.

Steep trendelenburg
-This places our pt at higher risks of certain cardiac, respiratory, neurophysiological changes.

Goal of robotic-assisted surgery

The goal of minimally invasive robotic procedures is to improve surgical outcomes and allow patients to return to normal activity as quickly as possible

What 2 specific things about robotic surgeries caused increased risk of injury?

Extreme surgical positions necessary for robot
Prolonged surgery durations

We should assess our surgical positioning during robotic surgeries how often?

q15 mins or whenever the patient, robot, or table are moved around

What is mentioned as being one of the most common robotic surgeries worldwide?

The robotic-assisted laparoscopic prostatectomy (RALP)
-Less blood loss, shorter LOS, however more expensive

RALP Anesthesia, Positioning, Surgery

Anesthesia: GETA with NMB
Positioning: Steep trendelenburg and lithotomy
peroneal nerve damage risk in lithotomy
Surgery: Most common robotic

Trendelenburg considerations:

-Increases VR, CVP, ICP, IOP, PIP -Decreases lung compliance, tidal volumes, oxygen sats

Lithotomy considerations:

-May see falsely high BP and hypovolemia can be masked -Increased PIP, dead space -Decreased pulmonary compliance, tidal volumes

Most important risk (for us) with positioning changes?

Maintain that patent airway and ETT placement

____ ____ ____ accounts for 89% of post op vision loss due to hypotension.

Ischemic optic neuropathy (ION)

___ ___ ___ ___ causes post op vision loss from decreased blood supply to the entire retina. Most often due to improper positioning of the head.

Central retinal artery occlusion (CRAO)

*Repeat card on purpose* Signs and symptoms of CO2 embolism

-Decreased EtCO2, oxygen saturation -Increased EtN2 -Tachycardia, hypotension, dysrhythmias, CV collapse

*Repeat card on purpose* Most CO2 embolisms will resolve how?

Spontaneously with no treatment

*Repeat card on purpose* Treatment of CO2 embolus that will not resolve on its own

1. D/c insufflation, Stop N2O if using, give 100% O2 2. Deflate abdomen 3. Flood the field with saline 4. Place in left lateral position (durant maneuver) 5. Aspirate out of central line if present 6. Hemodynamically support the patient

What is the purpose of enhanced recovery after surgery (ERAS) protocols?

To enhance recovery management pathways and allow return to normal activity as soon as possible

Robotic cardiothoracic surgery Anesthesia and Positioning

Anesthesia: GETA with NMB Positioning: Modified left or right lateral position

Robotic cardiothoracic surgery Considerations

-May use prolonged one-lung ventilation -Continuous TEE and invasive monitoring may be in place