FLS Flashcards
(358 cards)
1
Q
How do the types of laparoscopes vary?
A
Diameter (2-10mm), length (30-45cm), and degree (0, 30, 45)
2
Q
What is the Hopkins rod lens system in a laparoscope? What is its limitations?
A
Susceptible to rod damage with use and processing, reduced light reaches the end of the endoscope
3
Q
What is an alternative method to capture an image via laparoscope besides the Hopkins rod lens system?
A
Have an imaging chip at the end of the scope, no light is lost as the image travels back
4
Q
When is a zero-degree laparoscope preferable?
A
When working in a small area where you need to directly visualize the field: pelvis, high in mediastinum
5
Q
When is a 30 or 45-degree scope preferable?
A
allows you to see more breadth of the field
6
Q
Why do you need standard open instruments when performing lap surgery?
A
to help open and close port sites as well as possible conversion to open
7
Q
How can you check a rod-lens laparoscope for damage?
A
hold the lens end up to the light and look at the light cord attachment site for black spots indicating damage. Look at the lens end for obvious damage. Eval for moisture between scope and camera causing blurred image
8
Q
Why does the laparoscope fog?
A
changes in temp and humidity between room and in the body
9
Q
How can you prevent a foggy image?
A
anti-fogging solution, allow it to dry before entering the abdomen, rinse the scope in hot water, keep scope in an insulated bottle, or keep scope in a heated bath
10
Q
what do you do if the lens is smudged?
A
wipe on clean tissue (liver, bowel), remove scope and clean on gauze + clean the mechanical seal of the port with gauze
11
Q
what is the most commonly used gas for laparoscopy and why?
A
CO2 - readily available, inexpensive, non-combustible
12
Q
What should you have available if your gas supply comes from a tank?
A
An additional full tank with appropriately sized wrench attached to the insufflator + supply of new gaskets for the tanks
13
Q
what is the clincial difference in using warmed and humidified CO2 for laparoscopy and when is it relevant?
A
significant reductions in postop pain, not significant for operations lasting less than 90 minutes
14
Q
what does the insufflator do?
A
controls the flow of CO2 gas into the abdomen
15
Q
how fast does a high-flow insufflator deliver gas? (rate)
A
10-15 LPM
16
Q
what are the two controllable panels on the insufflator
A
gas flow rate and preset max pressure in the abdomen
17
Q
what is displayed on the insufflator?
A
current abdominal pressure and amount of gas used
18
Q
what is the reason a filter is attached to the gas line?
A
to prevent patient’s body fluids refluxing back into the insufflator, risk of transmission to the next patient
19
Q
how many suction devices do you need in the room at a minimum?
A
3: one for anesthesia, one for NGT, and one for the operation
20
Q
how can using a suction device affect pneumoperitoneum and how can this be prevented
A
excessive suctioning can decrease pneumoperitoneum, prevent by fully immersing the suction catheter into the liquid being suctioned
21
Q
What are the four components of the video tower?
A
light source, camera control unit, video monitor, insufflator
22
Q
what is the most common light source?
A
300W Xenon lamp
23
Q
why should you connect the light source to the laparoscope prior to turning it on?
A
to avoid blinding OR staff and risk of fire if light cord contacts OR drapes
24
Q
what is used to help light travel from the light source to the laparoscope? What is it made of?
A
A light cable made of fiberoptic elements
25
How do you check a light cord for damage
hold one end of the cord to light and the other to your eye to look for black dots, which indicate broken fibers
26
How can you capture still images / video from laparoscopic surgery for inclusion in chart / literature?
digital capture that saves images to CD, DVD, hard disk, or other removable drive. Printers can be used as well.
27
What is the "Picture in Picture" Effect and when is it most useful?
Allows both images from the laparoscope and additional imaging to be projected on the same screen. Useful if you need to use intraoperative Doppler, ultrasound, or endoscopy
28
What are the 9 preoperative precautions the circulator RN must perform prior to the patient entering the OR?
1) Assure OR TABLE is properly set up for the procedure, ensure tilt mechanism is functional, have bean bag mattress avaible if needed, have lead shielding available if fluoroscopy is planned, have foot board ready if needed. 2) check all POWER SOURCES are connected and switched on. 3) check for adequate CO2 available, extra tanks prn, and insufflator alarm is functional. 4) BOVIE: proper audio alarm function, grounding pad available. 5) VIDEO monitors operational and positioned appropriately, test pattern appears before monitor plugged in. 6) SUCTION/IRRIGATION - canister set up, irrigation bag available if needed. 7) SCDs, Foley, NGT available. 8) video documentation with CD/DVD available. 9) minimize floor clutter
29
What are the 8 preop precautions the circulator RN must perform after the patient enters the OR?
1) preop timeout to verify pt ID and procedure being performed. 2) assist in proper patient positioning and padding. 3) safety strap to patient. 4) after induction, apply grounding pad to patient and attach to electrocautery unit. 5) after pt prepped/draped, connect all lines from sterile field (camera cord, light source, suction/irrigation, cautery, CO2 tubing). Verify suction function/connection. 6) position foot pedals prn (U/S, cautery). 7) Apply SCDs. 8) complete checklist of Pt Prep for Surgery
30
What 7 preop precautions should the Scrub Tech/RN perform after the patient enters the room?
1) check fx of reusable instruments: movement of instrument handles and jaws, sealing caps for cracked rubber, instrument cleaning channel screw caps in place. 2) Check Veress needle: proper plunger/spring action, easy flushing through stopcock/needle channel. 3) if Hasson entry - check for available stay sutures and retractors. Availability of accessory trocars. 4) close all stopcocks on all ports. 5) check laparoscope for clarity / vision. 6) draw up local anesthetic and injection syringe. 7) if cholangiography anticipated, mix and dilute cholangiogram contrast solution. Evacuate cholangiography tubing, syringe, and catheter of all bubbles.
31
Name nine possible reasons for poor insufflation / loss of pneumoperitoneum
CO2 tank empty / low volume; accessory port stopcock open; leak in sealing cap / reducer; excessive suctioning pressure; loose, disconnected, or kinked insufflation tubing; Hasson stay sutures loose; CO2 flow rate too low; valve on CO2 tank not fully open; leak at skin where port enters cavity
32
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 CO2 tank empty / low volume
change tank
33
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 accessory port stopcock open
inspect all accessory ports. Open or close stopcocks prn.
34
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 leak in sealing cap / reducer
change cap or stopcock cannula
35
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 excessive suctioning pressure
allow time to reinsufflate, lower suction
36
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 loose, disconnected, or kinked insufflation tubing
tighten connections or reconnect at source / port or unkink tubing
37
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 Hasson stay sutures loose
replace or secure sutures
38
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 CO2 flow rate too low
adjust flow rate
39
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 valve on CO2 tank not fully open
use valve wrench to open fully
40
What do you do for poor insufflation / loss of pneumoperitoneum 2/2 leak at skin where port enters cavity
apply penetrating towel clip or suture around port
41
What are five possible causes of excessive pressure required for insufflation (initial or subsequent)?
Veress needle/cannula is not in the peritoneal space; occlusion of tubing (kinking, table joints, etc.); CO2 port stopcock is turned off; patient is "light" on anesthesia; morbidly obese patient
42
What do you do for excessive insufflation pressure 2/2 Veress needle/cannula is not in the peritoneal space
reposition needle or cannula under visualization if possible
43
What do you do for excessive insufflation pressure 2/2 occlusion of tubing (kinking, table joints, etc.);
inspect full length of tubing
44
What do you do for excessive insufflation pressure 2/2 CO2 port stopcock is turned off
fully open stopcock
45
What do you do for excessive insufflation pressure 2/2 patient is "light" on anesthesia
communicate to anesthesia
46
What do you do for excessive insufflation pressure 2/2 morbidly obese patient
use a longer Veress needle
47
What are 10 possible reasons for inadequate lighting during lap surgery?
light is dim; light is on standby; loose connection at source or scope; light is on "manual-minimum"; fiber optics are damaged; automatic iris adjusting to bright reflection from instrument; monitor brightness is turned down; room brightness floods monitors; bulb is burned out; scope is dark
48
What should you do for inadequate lighting during lap surgery 2/2 light is dim
increase gain, check scope for adequate fiberoptics, replace light cable, laparoscope and/or camera
49
What should you do for inadequate lighting during lap surgery 2/2 light is on standby
take light off standby
50
What should you do for inadequate lighting during lap surgery 2/2 loose connection at source or scope
adjust connection
51
What should you do for inadequate lighting during lap surgery 2/2 light is on "manual-minimum"
go to "automatic"
52
What should you do for inadequate lighting during lap surgery 2/2 fiber optics are damaged
replace light cable
53
What should you do for inadequate lighting during lap surgery 2/2 automatic iris adjusting to bright reflection from instrument
reposition instruments or switch to "manual"
54
What should you do for inadequate lighting during lap surgery 2/2 monitor brightness turned down
readjust brightness settings, adjust gain
55
What should you do for inadequate lighting during lap surgery 2/2 room brightness floods monitors
dim room lights
56
What should you do for inadequate lighting during lap surgery 2/2 bulb is burned out
replace bulb
57
What should you do for inadequate lighting during lap surgery 2/2 scope is dark
check white balance
58
What are three reasons you could have a poor quality picture with lap surgery?
flickering electrical interference / poor cable shielding; color problems; glare not caused by lighting
59
What should you do for poor quality picture 2/2 flickering electrical interference / poor cable shielding
replace cautery cables, switch camera head, make sure cables don't cross, use different plug points
60
What should you do for poor quality picture 2/2 color problems
white balance camera, check chrome on monitor, check printer/VCR/digital capture cables
61
What should you do for poor quality picture 2/2 glare not caused by lighting
check for loose cables not plugged in
62
What are two reasons lighting could be too bright during lap surgery?
light is on "manual - maximum"; monitor brightness is turned up
63
What should you do if lighting is too bright 2/2 light is on "manual - maximum"
"Boost" on light source is activated - go to "automatic and deactivate "boost"
64
What should you do if lighting is too bright 2/2 monitor brightness is turned up
readjust setting
65
What are five reasons there is no picture on the monitor during lap surgery?
camera control / other components (VCR, printer, light source, monitor) are not turned "on"; cable connector between camera control unit and/or monitors are not attached properly; cables between monitors are not connected; input select button on monitor doesn't match "video in" choice; input selection button on monitor or video peripherals (VCR/digital capture/printer) are not selected
66
What should you do if there is no picture on the monitor 2/2 camera control / other components (VCR, printer, light source, monitor) are not turned "on"
make sure all power sources are plugged in and turned on
67
What should you do if there is no picture on the monitor 2/2 cable connector between camera control unit and/or monitors are not attached properly
cable should run from "video out" on camera control unit to "video in" on primary monitor. Use compatible cables for camera in and light source.
68
What should you do if there is no picture on the monitor 2/2 ables between monitors are not connected
cable should run from "video out" on primary monitor to "video in" on secondary monitor
69
What should you do if there is no picture on the monitor 2/2 input select button on monitor doesn't match "video in" choice
assure matching selection
70
What should you do if there is no picture on the monitor 2/2 input selection button on monitor or video peripherals (VCR/digital capture/printer) are not selected
adjust input selection
71
What are two reasons that you could have poor quality picture with fogging/haze?
condensation on lens from cold scope entering warm abdomen; condensation on scope eyepiece / camera lens
72
What should you do with poor quality picture with fogging/haze 2/2 condensation on lens from cold scope entering warm abdomen
use anti-fog solution or hot water, wipe lens externally
73
What should you do with poor quality picture with fogging/haze 2/2 condensation on scope eyepiece / camera lens
detach camera from scope (or camera from coupler); inspect and clean lens as needed
74
what are three reasons you could have poor quality picture with flickering / electrical interference
moisture in camera cable connecting plug; poor cable shielding; insecure connection of video cable between monitors
75
what should you do with poor quality picture with flickering / electrical interference 2/2 moisture in camera cable connecting plug
use suction or compressed air to dry out moisture (don't use cotton tip applicators on multi-pronged plug)
76
what should you do with poor quality picture with flickering / electrical interference 2/2 poor cable shielding
move electrosurgical unit to different circuit or away from video equipment, make sure cables do not cross, switch camera head; replace cables as necessary
77
what should you do with poor quality picture with flickering / electrical interference 2/2 insecure connection of video cable between monitors
reattach video cable at each monitor
78
What are three reasons for poor quality picture with blurring / distortion?
incorrect focus, cracked lens/internal moisture, too grainy
79
What should you do for poor quality picture with blurring / distortion 2/2 incorrect focus
adjust camera focus ring
80
What should you do for poor quality picture with blurring / distortion 2/2 cracked lens / internal moisture
inspect scope / camera, replace if needed
81
What should you do for poor quality picture with blurring / distortion 2/2 too grainy
adjust enhancement and/or grain setting for units with this option
82
What are four reasons for inadequate suction / irrigation?
occlusion of tubing (kinking, blood clot, etc.); occlusion of valves in suction / irrigator device; not attached to wall suction; irrigation fluid container not pressurized
83
What should you do for inadequate suction / irrigation 2/2 occlusion of tubing (kinking, blood clot, etc.)
inspect full length of tubing. Detach from instrument and flush with sterile saline prn.
84
What should you do for inadequate suction / irrigation 2/2 occlusion of valves in suction / irrigator device
detach tubing, flush device with sterile saline
85
What should you do for inadequate suction / irrigation 2/2 not attached to wall suction
inspect and secure suction & wall source connector
86
What should you do for inadequate suction / irrigation 2/2 irrigation fluid container not pressurized
inspect pressure bag / compressed gas source, connector, pressure dial setting
87
What are six reasons for absent or "weak" cauterization
patient not grounded properly; connection between electro-surgical units and instrument loose; foot pedal or hand switch not connected to electrosurgical unit; wrong output selected; connected to wrong socket on electrosurgical unit; instrument insulation failure outside of surgeons view
88
What should you do for absent / weak cauterization 2/2 patient not grounded properly
assure adequate grounding pad contact
89
What should you do for absent / weak cauterization 2/2 connection between electro-surgical units and instrument loose
inspect both connecting points
90
What should you do for absent / weak cauterization 2/2 foot pedal or hand switch not connected to electrosurgical unit
make connection
91
What should you do for absent / weak cauterization 2/2 wrong output selected
correct output choice
92
What should you do for absent / weak cauterization 2/2 connected to wrong socket on electrosurgical unit
check that cable is attached to endoscopic socket
93
What should you do for absent / weak cauterization 2/2 instrument insulation failure outside of surgeons view
use new instrument and inspect insulation
94
what does a low pressure and high flow rate on the insufflator indicate?
leak in the insufflation circuit
95
what should you suspect if the foley bag begins to inflate?
insufflation of bladder
96
what should you suspect if you have a small working space and dilation of bowel?
insufflation of bowel
97
what should you do if there is a loss of working space and no flow on the insufflator?
make sure the power is on and the insufflator is not in standby mode
98
what are the two choices of delivery of electrocautery to the patients?
monopolar or bipolar instruments
99
how does the monopolar current flow?
from the wall source, through the instrument, grounded by the patient
100
what two processes occur to tissue to allow electrocautery to assist with hemostasis
protein coagulation and tissue dessication. You get fibrous binding of dehydrated and denatured cells and vessel endothelium
101
Define current density. What is it directly and indirectly proportional to?
the amount of current flowing through a cross-sectional area of tissue. directly proportional to applied power (amps), inversely proportional to tissue resistance and area of tissue through which the current must travel (cm2)
102
where should the grounding pad NOT be placed on the patient?
should not be bent or placed on hairy skin, bony prominences, or scars b/c they decrease contact surface area and = increased current density and increased risk of burns
103
what are the three modes of monopolar electrocautery?
cut, coag, or blended
104
what is the goal of cutting mode and how does it work?
quickly heat tissue, vaporize, cause cells to explode. heat is dissipated in the steam, causing minimal lateral thermal tissue damage and poor thermal coagulation
105
what is the goal of coagulation mode and how does it work?
rapid surface heating with superficial eschar formation and shallow depth of necrosis, this process is aka fulguration. This is seen with an intermittent, high-voltage waveform, minimal cutting, relies on sparking between electrode and tissue
106
What does the blend mode accomplish
blends the cutting and coag modes to allow the surgeon to adjust for desired tissue effects
107
What is "current diversion"?
Current, following the path of least resistance, current passes through unintentional tissue. Relevant to laparoscopic surgery b/c the entire field is not always in the surgeons view.
108
name eight precautions you can take to minimize risk of electrosurgical injury during lap surgery
1) inspect insulation carefully; 2) use lowest possible power setting; 3) use lowest voltage waveform possible; 4) use brief intermittent activation rather than prolonged activation; 5) do not activate unless in proximity to target tissue; 6) do not activate in close proximity or direct contact with another instrument; 7) use bipolar instrumentation when appropriate; 8) do not use hybrid laparoscopic ports that mix metal with plastic
109
What is "Capacitive Coupling"?
transfer of current from active electrode through its insulation through passive electrode. There must be two conductors separated by an insulator for this to occur and may result in burns from the passive electrode.
110
What happens with capacitive coupling if the passive electrode is in constant contact with adjacent tissue
no burns because this allows the passive electrode to release charge through the tissue to the ground without holding onto/building up the charge
111
How can Capacitive Coupling occur with another laparoscopic instrument?
When the electrocautery instrument comes into contact with another insulated instrument. Particularly dangerous if the second instrument is not in constant contact with tissue, allows the instrument to store energy --\> means that it will discharge next time it touches tissue --\> tissue injury
112
What is Direct Coupling and how can it result in tissue injury?
when electrocautery touches metallic portion of another instrument, charge goes down through instrument to any tissue its touching. With laparoscopes in particular, can result in damage to tissue outside the field of view.
113
What is a Narrow Return Circuit and how can it result in tissue injury?
if monopolar electrocautery applied to ligated tissue, the current will pass through the smaller ligated area with increased current density --\> may result in delayed tissue blowout
114
How does bipolar cautery differ from monopolar in terms of current flow, patient prep, and danger to surrounding tissues?
Bipolar has the current flow between the two electrodes in the field, so only the tissue in between has electric flow through it. No need for grounding pad and reduced risk of damage to surrounding tissue (lower energy requirement, less risk of coupling).
115
Name three potential hazards of bipolar tissue sealing devices
inadvertant thermal injury; inadvertant cutting off patent vessels before adequate sealing; improper device function if metal is contained within the jaws (ie clips or surgical staples)
116
what type of energy does ultrasonic coagulation rely on to produce its effects?
mechanical energy --\> heating through high frequency ultrasonic vibration
117
how does sealing occur with ultrasonic coagulation in terms of tissue in between the jaws of the instrument?
when the tissue is in between the vibrating and heated metallic jaw (active blade) and the passive plastic jaw (acts as a backstop to hold tissue against the active blade
118
what is the most common use of the ultrasonic coagulation
ultrasonic shears
119
what is the danger of injury to surrounding tissue with ultrasonic coagulation with shears and what can you do to prevent injury?
the passive jaw does not transfer energy but the unprotected active jaw will transfer energy so you need to be sure its not touching other tissue. Be aware of the contact points, grab the target tissue and elevate it, and keep the active blade upward.
120
What is the frequency of oscillation of the ultrasonic coagulation?
50,000 Hz (x/second)
121
What are the effects of different power settings with ultrasonic coagulation?
lower power settings: hemostasis. Higher power settings: cutting
122
what should you consider with patient positioning if they will require X-rays during surgery?
make sure you can fit the C-arm or plate under the patient during surgery
123
where should monitors be placed during surgery and why?
at or below eye level to reduce strain
124
where should the insufflator be placed during surgery and why?
in a location where surgeon and assistants can view it during the procedure
125
where should the surgeon stand and what should their hand/arm/shoulder position be?
opposite to the operative field, shoulders within 30 degrees of body, forearm at 60 to 120 degrees, wrist slightly pronated, thumbs up
126
what are six important aspects of medical history to obtain preop?
1) prior abdominal / pelvic surgery; 2) prior abdominal radiation - including site; 3) hip prosthesis/other prosthetic device (affects positioning); 4) pulmonary / cardiac disease; 5) previous DVT / coagulation disorders; 6) anesthetic complications from prior surgeries
127
what patient home medications are important to know about preop
steroids, immunosuppressants, pulm/cardiac meds, anticoagulation (hold coumadin 3 days prior), NSAIDS (don't need to hold)
128
what pt allergies are important to know about preop
meds (local anesthetics), skin prep (betadine)
129
define ASA class I
no organic, physiologic, biochemical, or psychiatric disturbance
130
define ASA class II
mild to moderate systemic disease, due either to surgical condition or to a concomitant disease
131
define ASA class III
severe systemic disease that limits the patients activity and may / may not be related to the reason for surgery
132
define ASA class IV
severe systemic disturbances that markedly limit the patient and are life threatening with or without surgery
133
define ASA class V
moribund patient who has little chance for survival but is submitted to surgery as last resort (resuscitative effort)
134
which ASA classes cannot tolerate lap surgery and why?
ASA IV and V cannot usually tolerate the decreased venous return, decreased diaphragmatic excursion, and hyperventilation a/w pneumoperitoneum
135
Name four absolute contraindications to lap surgery
inability to tolerate laparotomy, hypovolemic shock, lack of proper surgeon training/experience, lack of appropriate institutional support
136
name five relative contraindications to lap surgery
inability to tolerate general anesthesia, long-standing peritonitis, large abdominal / pelvic mass, massive incarcerated ventral / inguinal hernias, severe cardiopulmonary disease
137
What preop precautions should you take for visceral arterial aneurysm?
increased risk of injury with trocar insertion
138
What preop precautions should you take for previous abdominal surgery?
pt may have extensive adhesions, increased risk of enterotomy, do not insert Veress needle to close to previous scar
139
What preop precautions should you take for history of peritonitis?
higher risk of extensive adhesions and increased risk of enterotomy
140
What preop precautions should you take for umbilical abnormalities? (mass, existing hernia, or history of previous umbilical hernia / ventral hernia repair)
difficulty gaining access intraabdominally or closing fascia. Avoid blind techniques near umbilicus to gain access to abdomen
141
What preop precautions should you take for previous ventral hernia repair with mesh? Why is this particularly important for laparoscopic ventral hernia repair?
Risk of injury with trocar insertion, extensive adhesions, difficulty closing abdominal wall, risk of infection. If previous lap ventral hernia repair with mesh, you may not be able to see the scars. You should never attempt entering the abdomen through previous mesh.
142
What preop precautions should you take for pts with hepatosplenomegaly?
increased risk of solid organ injury or poor exposure
143
What preop precautions should you take for pts with cirrhosis?
increased risk of ascites leak and bleeding. Should attempt to medically control ascites prior to elective lap surgeries.
144
What preop precautions should you take for intestinal obstruction
bowel dilation increases risk of enterotomy and decreases visualization
145
What preop precautions should you take for pregnancy
precautions to avoid entry to the gravid uterus and optimize for physiology of the pregnant patient
146
What preop precautions should you take for thin body habitus
less space between intraabdominal organs and anterior abdominal wall - especially important with blind insertion
147
What are five relative contraindications to lap chole?
gallbladder cancer, portal HTN, cirrhosis, acute cholecystitis, and Mirizzi syndrome
148
What are two relative contraindications to lap appy?
phlegmon, large abscess
149
What are four relative contraindiations to lap colectomy?
large fixed mass, dense pelvic adhesions, massive bowel dilation, and T4 tumors
150
what are three relative contraindications to emergency laparoscopy?
longstanding peritonitis, hemodynamic instability partially correctable with resuscitation, massive bowel dilation
151
what are two relative contraindications to pelvic laparoscopy?
large, fixed masses; inability to tolerate Trendelenburg postion
152
what are two relative contraindications to lap foregut procedures?
previous gastric operation, especially at GE junction; hepatosplenomegaly
153
What are five relative contraindications to lap antireflux surgery?
esophageal shoreting, epihtelial dysplasia, previous gastric surgery (especially operations at the GE junction), liver enlargement, and large hiatal hernias
154
Wha are five relative contraindications to lap hernia repair
large, chronically incarcerated hernias; acutely incarcerated hernias requiring bowel resection, need for removal of large prosthetics; need for skin graft removal or large scar revision
155
Name 9 conditions that are commonly mistaken as contraindications to laparoscopy
diaphragm injury, GI bleed, perforated viscus, bowel obstruction, abdominal trauma intrauterine/ectopic pregnancy, obesity, COPD, renal insufficiency
156
When should you consider laparoscopy and/or thoracoscopy for trauma?
only when there are no life-threatening injuries to the patient and they do not have an uncorrectable hemodynamic instability. laparoscopy can determine if there is peritoneal violation and injury after penetrating abdominal wounds.
157
What is the initial imaging test of choice in pregnant patients?
ultrasound is safe and effective in identifying etiology of acute abdominal pain.
158
What is your ddx for the pregnant patient with acute abdominal pain:
adnexal mass, torsion, placental abruption, placenta previa, uterine rupture, fetal demise, sx cholelithiasis, cholecystitis, appendicitis.
159
what should be the limit of ionized radiation exposure to the fetus and why?
limit cumulative radiation to 50-100 mGy during pregnancy to reduce risk of teratogenesis and childhoood leukemia
160
how much ionized radiation is associated with radiographs?
1-3 mGy
161
how much ionized radiation is a/w a CT pelvis?
30 mGy
162
when should a CT scan be used in pregnancy?
may be used in emergency settings but is not the initial test of choice
163
what is the role of MRI in abdominal imaging in pregnancy
MRI without IV gadolinium can be performed at any stage of pregnancy and is preferred over CT for diagnosis of non-obstetric abdominal pain in gravid patients
164
why should you avoid gadolinium in the pregnant patient
IV Gadolinium crosses the placenta and may cause teratogenesis
165
when and how can intraop cholangiography be used in the pregnant patient
can use during surgery, shield the lower abdomen to protect the fetus
166
what are two alternatives to intraop cholangiogram in the pregnant patient
EUS, choledochoscopy
167
when is diagnostic laparoscopy indicated in the pregnant patient
start with imaging, if its unavailable or inconclusive, can move on to dx lap. Be careful bc it can have increased risk of preterm labor and fetal demise.
168
what are the benefits of laparoscopy in pregnant compared to nonpregnant patients
similar benefits between these two patient populations: less postop pain, reduced ileus, reduced LOS, faster return to work, reduced wound complications
169
how should you position the gravid patient and why?
Gravid patients beyond the first trimester should be placed in full /partial left lateral decub to minimize compression of the IVC
170
where and how should you access the gravid abdomen?
use Veress, Hasson, or optical trocar technique via a subcostal approach. Can use u/s guidance to avoid uterine injury.
171
what intraabdominal insufflation pressure can be used in the pregnant patient?
10-15mmHg, adjust for patient physiology
172
How should you monitor intraop CO2 in the gravid patient?
via capnography (ETCO2)
173
what DVT prophylaxis should be used in lap surgery for the pregnant patient?
SCDs, early ambulation. Can use unfractionated heparin if needed.
174
What is the recommended treatment of symptomatic gallbladder disease in the pregnant patient and why
Treat with lap chole regardless of trimester. If gallbladder dz remains uncomplicated, rates of spont abortion and preterm labor are similar between op and nonop management. If pts have recurrent symptoms and develop complicated disease (acute cholecystitis, cholangitis, gallstone pancreatitis) can result in higher rates of preterm labor and fetal loss
175
what is the recommended treatment for choledocholithiasis in pregnancy?
preop ERCP with sphincterotomy then lap chole with lap CBD exploration or postop ERCP
176
what is the treatment of choice for pregnant patients with acute appendicitis?
lap appy , very low rates of preterm labor and fetal demise
177
what type of imaging reduces the negative exploration rate for suspected appendicitis in pregnant patients?
MRI reduces the negative exploration rate by 50%
178
how should you manage a pregnant patient who requires a lap adrenalectomy, nephrectomy, or splenectomy?
can be performed safely during pregnancy, but if it can be delayed until after childbirth, it should be
179
in a pregnant patient, what is the management of symptomatic ovarian cystic masses that are less than 6cm and u/s is not concerning for malignancy + negative tumor markers (CA125, LDH)?
laparoscopy and observation
180
when should an ovarian mass be removed in the pregnant patient?
if it persists after 16 weeks and is \> 6cm in diameter
181
what is the treatment of ovarian torsion in the pregnant patient?
laparoscopy for dx and tx of ovarian torsion. If treated early, can just detorse. If later, may have to resect the gangrenous ovary to prevent peritonitis which could --\> spontaneous abortion
182
when during laparoscopic surgery should the fetal heart be monitored?
pre and postoperative fetal heart monitoring for viable fetuses (lower limit of viablity 22-24 wks)
183
when are tocolytics indicated in pregnant patients undergoing laparoscopic surgery?
do not give prophylactically, but can be used when the patient has signs of preterm labor perioperatively
184
how is laparoscopy useful for peritonitic patients
can assist in dx and planning for an open or lap approach to treatment
185
what type of abdominal entry is preferable for bowel obstruction patients and why?
prefer direct visualization to enter the abdomen to prevent enterotomy, especially with SBO
186
how can you find the transition point for SBO during lap surgery?
go from the decompressed loops of bowel and travel proximally to avoid handling the dilated loops of bowel
187
what is the laparoscopic surgical intervention for large bowel obstruction?
proximal diverting ostomy
188
what can you do to establish intraabdominal access in the obese patient?
longer Veress needle perpendicular to the abdominal wall, use of spinal needles, trocars \> 100mm in length
189
why is there a high risk of vascular injury in entering the abdomen of thin or muscular patients?
aorta and iliac vessels are in close proximity to the abdominal wall
190
how can you avoid vascular injury when entering the abdomen in thin / muscular patients
elevating the abdominal wall, entering the abdomen by the costal margin, use open approach or visual trocar
191
what three laparoscopic procedures can be performed under local anesthetic?
diagnostic laparoscopy, tubal ligation, select inguinal hernia repairs
192
what is the max dose of lidocaine without epi? (mg/kg)
4 mg/kg
193
what is the max dose of lidocaine with epi? (mg/kg)
7 mg/kg
194
what is the max dose of bupivicaine without epi? (mg/kg)
2 mg/kg
195
what is the max dose of bupivicaine with epi? (mg/kg)
3 mg/kg
196
what is the max dose of ropivacaine without epi? (mg/kg)
2 mg/kg
197
what is the max dose of ropivacaine with epi (mg/kg)?
3 mg/kg
198
when should epidural anesthesia be used with laparoscopy? What are its benefits?
may be used alone in selected cases, adjunct to GA sometimes. Helps reduce postop pain and postop ileus.
199
what are the indications for using atropine and/or glycopyrrolate during laparoscopy?
the pneumoperitoneum may cause bradycardia, however atropine is a/w dry mouth so preferable to use after patient is induced and only prn not preventive
200
why should a patient receive H2 blocker or sodium citrate prior to general anesthesia?
to reduce effects of aspiration if it occurs
201
how should patient's arms be positions for procedures in the pelvis / lower abdomen?
tuck one or both arms to allow surgeons to position themselves by the mid/upper abdomen
202
how should the patient's arms be positioned for procedures in the upper abdomen?
shoulders /arms can be left out at a 90 degree angle
203
why is it important to keep arms at 90 degrees and pad them?
to avoid brachial plexus injury and pressure point injuries
204
when tucking arms, why is it important to keep them away from a break in the table?
avoiding hand injury if the table is flexed during the operation
205
what two additional safety measures / equipment should be used if you plan on using reverse trendelenberg during the surgery?
safety strap across the knees to prevent buckling, foot board to prevent sliding
206
what should be placed under the dependent axilla to prevent brachial plexus injury in lateral decub?
place shoulder roll under axilla to prevent brachial plexus injury
207
how shoudl the upper arm be positioned when the patient is in lateral decub?
place in a sling or on a padded surface (stack of blankets/towels) to allow it to have adequate support
208
when using a beanbag for a patient in lateral decub, how far up the abdomen can the beanbag go and why?
can go up to midline of the abdomen, should not go past that b/c will interfere with port placement
209
why should you pad the beanbag when required for patient positioning?
becasue it can be harder than pillows, so should pad it to prevent injury
210
what adjustment can be made in positioning when the patient is lateral decub to plan for lap nephrectomy / adrenalectomy to optimize working space
can flex the OR table to allow increased space between the costal margin and iliac crest
211
What is the Veress Needle?
A spring-loaded needle witha sharp tip that serves as the conduit for insufflation gas
212
why is the umbilicus the most frequently chosen location for entry into abdomen?
abdominal wall is thinnest at that location and its centrally located
213
list the steps of veress needle insertion
skin incision below the umbilicus to allow the needle to pass through (size of incision depends on if you will be placing trocar through the site); lift up the abdominal wall (both surgeon and assist do this) by grasping skin and muscle to allow increased distance; hold veress needle like a pencil; pass needle thru incision perpendicular to the abdominal wll; can feel a pop / hear a click when you pass through the peritneum; if no further resistance, you are likely in and the tip of the needle should be mobile;
214
how can you verify that the veress needle is intraperitoneal? (8 ways)
loss of resistance with insertion ; audible click as inner blunt, spring-loaded trocar releases; freely mobile tip; no aspiration of blood or enteric contents; low insufflation pressure with low to medium flow; free flow of saline; hanging drop test; tympany with percussion of abdomen after insufflation
215
what is the most accurate way to verify the Veress needle is intraperitoneal
attaching gas at a low - medium flow rate and, if pressure stays low, you are likely intraperitoneal.
216
After you place the Veress needle and attach gas, pressure is high. What could this mean and how do you fix it?
Could mean that you are still in the abdominal wall or up against the viscera. If the latter is true, lifting up the abdominal wall should reduce the pressure and allow gas to fill the peritoneal cavity.
217
how do you perform the "hanging drop test" for Veress needle placement?
fill the needle with saline up to the brim. If you lift the abdominal wall and the saline does not flow out, you are still in the abdominal wall. If you lift the abdominal wall and the saline flows out, you are in the peritoneum.
218
what is the desired intraabdominal pressure and how much CO2 does it take to get there?
desire 10-15mmHg, requires 1-3L CO2
219
name two relative contraindications to blind initial trocar insertion
previous abdominal surgeries, previous intraabdominal inflammatory process
220
name two absolute contraindications to blind initial trocar insertion
abdominal scar from previous open operation in immediate vicinity of trocar insertion; placing trocar through previously placed intraperitonelal mesh for hernia repair
221
describe the technique for inserting a trocar after Veress needle pneumoperitoneum
trocar against thenar eminence; shaft between middle and index fingers, keep wrist straight, twisting motion combined with pushing motion, minimal pushing as possible
222
what is the first step after Veress needle and initial trocar placement
laparoscopic inspection of area immediately below needle and trocar insertion, scan surfaces of organs to eval for injury (enteric contents, blood)
223
what can you do if a patient has a midline abdominal scar and you want to use a Veress needle?
you can use a LUQ insertion, be sure to avoid epigastrics, can also use Hasson or optical trocar
224
Name eight potential complications of Veress needle insertion
bowel injury, mesenteric/omental vascular injury, RP vascular injury, cardiac arrhythmia, hypotension, high airway pressures, PTX, gas embolism
225
what should you immediately do if a patient has cardiopulmonary compromise?
immediate evacuation of pneumoperitoneum, eval for vascular injury
226
list the steps of the Hasson insertion
2cm periumbilical incision after elevating skin with 11 blade; carry down through SQ to fascia; use Kocher to elevate the fascia; use S retractor to expose fascia, incise with blade or cautery; Place anchoring sutures on each side or horizontal mattress while the fascia is exposed; lift up peritoneum with clamps and cut open with scissors / scalpel; palpate and sweep with index finger
227
how do you insert the first trocar after Hasson entry
insert the trocar, secure with stay sutures; establish pneumoperitoneum; evaluate area around port entry for injury
228
how do you place additional trocars?
under direct visualization - push with finger or add in needle with local anesthetic and place trocar under direct visualization
229
how do you prevent hitting the epigastric vessels with trocar insertion?
avoid placing trocars in the middle of the rectus muscles, not usually able to see these vessels with transillumination
230
Name six patient signs / vitals that must be monitored during pneumoperitoneum
cardiac rhythm, pulse ox, ETCO2, heart rate, blood pressure, UOP
231
name five reasons why CO2 is preferred for pneumoperitoneum
rapidly absorbed, easily eliminated, suppresses combustion, readily available, relatively inexpensive
232
what happens to patient's pH and ETCO2 duringthe first 20 minutes of insufflation? How does this affect anesthesia monitoring?
CO2 absorbed by the blood, overwhelms the buffering system, leading to increased PaCO2, decreased serum pH, and increased end tidal CO2. This means that you need to monitor ETCO2 vigilantly during the establishment of pneumoperitoneum, especially in severe cardiopulmonary dz.
233
name four alternative bases to CO2 to establish pneumoperitoneum
nitrous oxide; air; helium; argon
234
what are the risks and benefits of nitrous oxide for pneumoperitoneum
Benefits: less acid-base disturbances, may be better tolerated in pts with severe cardiopulmonary dz, tolerated relatively well without GA, slightly less postop pain. RISKS: fire hazard if using electrocautery in presence of open bowel (supports combustion b/c O2 from tract)
235
what are the risks and benefits of argon and helium for pneumoperitoneum
much less soluble in blood, increased risk of extraperitoneal gas extravasation, much more expensive, insufflators for their use are not readily available
236
what are the 3 CV changes with pneumoperitoneum
increased preload, increased afterload, and decreased CI
237
HOw is cardiac output affected by CO2 pneumoperitoneum
decreased CO exacerbated by reverse trendelenberg, hypovolemia, underlying cardiac disease, and vagally induced bradycardia
238
What should you do preoperatively to reduce risk of cardiovascular collapse during pneumoperitoneum?
make sure pt received all prescribed cardiac meds the AM of surgery, account for pt hydration status especially if they had a bowel prep
239
What should you do intraoperatively if a pt develops cardiac collapse?
Desufflate immediately, check insufflator settings and fx, check for adequate relaxation, check intravascular volume status, check for other causes of hypotension (bleeding)
240
is urine output a reliable indicator of intravascular volume during lap surgery?
no - pneumoperitoneum causes decreased renal blood flow, decreased UOP. Also increased renin and increased ADH release, reducing urine output further. This resolves within a few hours after surgery. Must be careful not to prescribe too much fluid --\> fluid overload
241
What are the risks of hypothermia with lap surgery
warmed IVF and warmed CO2 helps reduce risk, higher risk with longer cases
242
what are the risks of extraperitoneal gas extravasation
may be intentional, subcutaneous, thoracic, delayed CO2 toxicity, and gas embolus
243
What three maneuvers should be performed with laparoscopic equipment to prevent complications with pneumoperitoneum?
filter to protect insufflator, use clean tubing, keep cylinder upright to avoid liquid CO2 from escaping
244
what is the most common change in cardiac rhythm with pneumoperitoneum?
sinus tachycardia
245
what change in cardiac rhythm is associated with the pressure of pneumoperitoneum?
bradycardia - vagally mediated
246
what should you do if a patient becomes profoundly bradycardia during establishment of pneumoperitoneum
let out the air, stabilize patient, restart flow at lower rate, if pt cannot tolerate consider open procedure or aborting procedure
247
What are two procedure specific risk factors for DVT?
duration of procedure \> 1 hour (reduced lower extremity blood flow), pelvic procedures
248
What are 15 pt-specific risk factors for DVT?
history of VTE, age \> 40, immobility, varicose veins, CA, chronic renal failure, obesity, peripartum, CHF, MI, hormone replacement therapy, OCPs, multiparity (3), IBD, severe infection
249
what should you do before you leave the abdomen?
one last check for any visceral injury. Reduce pneumoperitoneum slightly to check for venous ooze.
250
Name three MC sources of unrecognized bleeding
trocar injury of abdominal wall vessels, injury to vessels or organs away from the operative field, or tamponade of venous bleeding
251
how can you laparoscopically place drains?
may pull through a 5mm port site with grasper or push through a 10-12mm port. Clamp drain tubing to prevent loss of pneumoperitoneum.
252
Why should you try to evacuate as much CO2 as possible after lap surgery?
to avoid postop pain
253
what are the three types of closures for port sites?
open, lap-assisted, entirely lap
254
what size port site does not need fascial closure and what is the exception
5mm dont need it except in peds
255
what is the rate of post op trocar site hernia?
5%?
256
How do you perform open closure of the fascia?
direct visualization with S-retractors, exaggerated needles, and may need to enlarge incision to alllow for exposure
257
what are two methods of fascial closure using lap-asssisted techniques?
use the carter-thompson to pass the suture through and bring it back out or use a keith needle to push the needle through, reverse intracorporeally, and back out
258
why are purely laparoscopic techniques of fascial closure not recommended?
exposure of the fascia is poor
259
name 10 peds surgical procedures performed laparoscopically
appy, undescended testes, anti reflux surgery, Hirschsprungs disease surgery, pectus repair, CV: PDA; esophageal / intestinal atresia, thoracic procedures, pyloromyotomy, exploration for contralateral hernia
260
name 12 gyn surgeries performed laparoscopically
tubal ligation, hysterectomy, hysteroscopy, endometriosois, LOA, adnexal surgery, myomectomy, CA staging, bladder neck suspension, pelvic floor procedures, ovarian procedures, oophorectomy
261
when is a diagnostic laparoscopy indicated?
can be under elective (cancer staging, chronic abdominal pain), urgent (SBO, ileus), or emergent (trauma, iatrogenic injury, perforated viscus) situations - if you need to determine dx
262
how can you take down adhesions during laparoscopically?
combination of sharp and blunt (sweeping motions) dissection, sparing use of electrocautery for hemostasis
263
when is diagnostic laparoscopy of the diaphragm indicated?
trauma
264
when is diagnostic laparoscopy of the liver indicated?
mass, tumor
265
when is diagnostic laparoscopy of the stomach/duodenum indicated?
PUD, perf, mass, tumor
266
when is diagnostic laparoscopy of the gallbladder indicated?
cholecystitis
267
when is diagnostic laparoscopy of the spleen indicated?
trauma, mass, infection
268
when is diagnostic laparoscopy of the LNs indicated?
cancer diagnosis or staging
269
when is diagnostic laparoscopy of the pancreas indicated?
mass, CA staging
270
how do you position the patient for upper abdominal laparoscopy?
arms out, reverse T (may need strap and foot board)
271
where should you place ports for upper abdominal diagnostic laparoscopy?
left - sided ports to allow you to visualize the entire abdomen. If you need to see the left abdomen as well, place a right port.
272
how should you position a patient for pelvic diagnostic laparoscopy?
arms tucked, trendelenburg
273
How should you plan to retract uterus for pelvic dx laparoscopy? (3 ways)
vaginal uterine manipulator, lap retractor, or suture retraction to abdominal wall
274
how should you run the bowel to evaluate for injury?
bowel runs from LUQ and RLQ. use atraumatic bowel graspers, typically all on left side. Begin at one end of the bowel and go to the other end, do not lose orientation. Try to grasp at the mesenteric fat rather than bowel wall. Avoid torquing the bowel wall when possible, esp with dilated bowel
275
what modifications should you make for dx lap for SBO
start at distal small bowel to start at decmopressed bowel. Work carefully b/c you have a reduced working space
276
how should you position a patient for a RP dx lap (spleen, aorta, kidney)
lateral decub +/- trendelenberg or RT.
277
what would you need to mobilize to eval RP structures?
may need to mobilize colon and periaortic LNs
278
how should you position a patient for dx lap for trauma?
arms tucked, supine
279
what is the benefit of dx lap for trauma?
good visualization of all organs, helps detect diaphragm and small bowel injury. Reduces nontherapeutic laparotomy rate
280
what type of scope should you use for dx lap for trauma?
30 degree scope
281
name five methods of laparoscopic bx
peritoneal washings and scrapings; FNA, core needle bx, incisional/wdge bx, excisional bx
282
why should you avoid electrocautery during biopsy
alters structure and compromises pathology exam. Get hemostasis after you obtain the specimen.
283
how do you perform FNA laparoscopically?
long enough needle (spinal) to reach target tissue thru abdominal wall, 20-22G needle, use short rapid strokes to hold suction and then pull out biopsy. Expel into container for cytology.
284
how do you perform core bx laparoscopically?
14-18G needle, usually used for liver. must avoid hemangiomas. specialized needles for this. Higher risk of bleeding after these bx, so need to either hold pressure, coagulation, or suture
285
what are biopsy forceps? What are they used for?
lap instrument with a cutting rim and hollow inside to avoid crushing the sample. Can be excisional or incisional depending on size of lesion.
286
How do you perform a wedge biopsy?
use scissors to get the sample, avoid use of energy source after tissue sample collected
287
what is the purpose of peritoneal washings?
cancer staging, planning therapy
288
when should you obtain peritoneal washings and how?
infuse 100cc of NS into the cavity immediately upon entering the abdomen. can agitate the abdomen and then collect the fluid with a collection device between the suction device and main suction canister. Sometimes needs to be mixed with heparin. Can also obtain cultures to ID infections. Dont need saline if pt has ascites.
289
how should you bx peritoneal lesions?
biopsy forceps, grasper + scissors, remove thru 5-10mm port
290
how do you bx LNs? Where are they ?
porta hepatis, peripancreatic, RP/periaortic. Tend to be excisional. Be gentle and then can use cautery or topical topical hemostatic agents or endoloop. Remove smaller nodes through 10-12mm port. Larger nodes through endocatch
291
how do you biopsy small surface lesions of the liver? liver?
incisiona or excisional biopsy. Can use core needle or wedge
292
how do you bx a large surface lesion of the liver?
core needle or wedge bx
293
how do you bx a lesion below the surface of the liver?
may need u/s to locate - FNA or core needle bx.
294
how do you bx liver cysts or vascular lesions
generally cysts don't need to be bx and you should avoid liver vascular lesion bx
295
what are the three methods to bx an ovary
oophorectomy, bx forceps, or small wedge resection on the antimesenteric section + fenestration of cyst wall
296
what three clinical factors are bx technique of the ovary based on?
menopausal status, suspicion for malignancy (if yes, oophorectomy), and frozen section findings
297
what is the full staging procedure for ovarian mass?
peritoneal washings, diaphragmatic sampling, paracolic gutter sampling bilaterally, periaortic LN sampling
298
how should you remove ovarian specimens and what are you trying to avoid
smaller specimens thru port, larter thru retrieval sac. You are trying to avoid seeding the abdominal wall
299
what is ovarian remnant syndrome
Ovarian remnant syndrome (ORS) occurs if any ovarian tissue is left after surgery to remove both ovaries and fallopian tubes, called a bilateral salpingo-oophorectomy. The syndrome occurs if this ovarian tissue causes severe pelvic pain and/or a pelvic mass.
300
how do you bx a visceral leison (on hollow viscus)
have a low threshold to close up the bx area to prevent postop leakage
301
when do you perform RP bx?
to get LNs or RP mass bx. can be transperitoneal or RP.
302
name six methods of hemostasis after bx
direct pressure, monopolar / bipolar electrocautery, argon beam, topical hemostatic, or sutures
303
why do you need to minimize bx exposure to port site?
to prevent seeding or losing the specimen
304
if an ovary is larger than 5cm or has complex internal us characteristics, what type of bx should you do?
oophorectomy
305
why are braided sutures easier to handle in laparoscopy
less memory and less kinking
306
why are dyed sutures preferred
becasue they don't blend into the background
307
what type of needle is preferred in laparoscoic surgery?
tapered needle
308
how far apart should ports be for intracorporeal knot tying?
ideally 10 cm apart
309
where should you grasp the needle wehn introducing into the abdomen?
5-10mm from the needle end
310
how can you introduce a needle into 5mm port sites?
put the port on the instrument itself and then the needle, introduce both into the abdomen
311
what are the sizes of lap clips?
5 and 10mm
312
what can be closed with clips?
used to close smaller tubular structures
313
linear staplers - what do they do?
place 2-3 rows of staples on each side of a knife blade and cut tissues between rows
314
how long are linear staple cartridges?
30-60mm
315
what type of port do staplers go through?
10-12mm port
316
what are smaller vs larger staples used for
smaller staples: hemostasis and thinner tissue, larger staplers for thicker tissue
317
what is a white/grey load height and whats it used for?
2-2.5mm, vascular & mesentery
318
what is a blue load height and whats it used for?
3-3.5mm, used for most of the GI tract
319
what is a green load height and what is it used for
4-4.5mm, used for distal stomach or unusally thick GI tract portions
320
how can you be sure the stapler is fully and appropriately engaged?
use articulating feature, view all the jaws
321
what do mechanical suturing devices accomplish?
needle introduction, needle positioning, passing needle thru tissue, tying the knot
322
name the five steps to laparoscopically control bleeding
1) optimize visualization: keep scope and port clean, may need to switch port. 2) grasp and hold bleeding source: atraumatic grasper, may apply direct pressure with instrument tip, gauze, pad, or hemostatic agent. 3) maintain exposure: use suction irrigator, may require additional port. 4) ID bleeding source: may need further dissection. 5) apply proper hemostatic techniques.
323
when should you consider conversion to open with bleeding?
failure to maintain hemodynamic stability or adequately control bleeding laparoscopically
324
what causes external port site bleeding and how can you control it
often from skin, SQ vessels, or muscle, caused by scalpel or trocar. Use electrocautery / sutures, may need to extend skin incision to get hemostasis
325
why is internal port site bleeding not always apparent?
because tamponaded with the port
326
why should you always remove ports under visualization
to see if any internal vessels injured with placement
327
what trocars are at highest risk of injuring epigastrics?
trocars through the rectus muscles
328
how do you stop internal hemorrhage from port site that has a slow rate of bleed with a visible source?
direct pressure or electrocautery
329
how do you control internal hemorrhage from port site with a high rate of bleed and no visible source?
control with grasper, may ontrol with foley cathter balloon if available, dissection to ID source, suture ligation and/or energy source as appropriate. May need full thickness adominal wall sutures with lap-assisted techniques. May need additional sutures or ports.
330
how do you perform a full thickness abdominal wall suture to control bleeding
small skin incision over bleeding site, place sutures procximal and distal to expected direction of vessels using lap-assisted technique: spinal needle, suture passer, or straight needle
331
what should you do with RP bleeding?
most likely convert to laparotomy to eval for source of bleedign: vascular or mesenteric
332
how can RP hemorrhage occur 2/2 Veress needle injury?
may have caused IVC or aortic injury with entry, be sure to evaluate for concomitant bowel injury
333
how can RP injury occur due to Trocars?
usually cause immediate blood loss, so lap control until you open
334
what are the indications for monopolar electrocautery for hemostasis
smaller vessels, slow rate of bleed, need a dry operative field
335
what are the indications for bipolar electrocautery for hemostasis?
larger vessels, works in wet operative fields, less lateral thermal spread, lower energy requirement
336
when can clips be used for hemostasis? what are the risks and benefits
need to be placed precisely on vessel, may dislodge if vessel is not completely dissected, may hamper subsequent efforts. Easy, single-handed deployement
337
what are the three types of suture that can be used for hemostasis
single, simple suture; figure of eight; endoloop / Roeder's knot
338
what is the use of hemostatic agents for control?
useful for slower rate of bleeding or raw surfaces. Not good for arterial bleeding b/c will just float off
339
what steps should you take with larger vessel ligation?
dissect, avoid endoloop with large arteries - prep for proper suture ligation, appropriate energy source, or vascular stapler. Prepare to immediately grasp vessel with grasper in case hemostatic method is not completely successful
340
how long do laparoscopic patients need to keep their wounds dry?
24-48 hours after surgery
341
how many days after a lap appy till a patient can tolerate a regular diet
0-1 days
342
how many days after a lap chole till a patient can tolerate a regular diet
0-1 days
343
how many days after a lap fundoplication till a patient can tolerate a regular diet
1-2 days
344
how many days after a lap colectomy till a patient can tolerate a regular diet
3-6 days
345
what are the three subtypes of postop complications?
injuries not identified at the time of the operation, partial thickness injuries, and other complications secondary to laparoscopy
346
what 5 viscera are most commonly injured by lap surgery?
stomach, small bowel, colon, bladder, ureters
347
what are four mechanisms of injury of viscera?
electrosurgical burn, full/partial thickness tear, anastomotic leak, devascularization/ischemia
348
how do visceral injuries present
4-7 days postop with fever, tachycardia, leukocytosis, and pain
349
what solid organs are most commonly injured by lap surgery?
liver, spleen, kidney, pancreas
350
what are four MOIs of solid organs?
capsular tear, retractuion injury, failed hemostasis, Veress needle
351
how do solid organ injuries present?
tachycardia, pain, anemia. Eval with CT if HDS
352
what vessels are most commonly injured and present postop?
tend to be smaller. Superior/inferior epigastric vessels or mesenteric arteries and veins
353
how do vascular injureis in the postop period present and how is it managed?
p/w anemia and hematoma, usu self limited but may require evacuation, may become infected
354
what are four mechanisms of nerve injury during lap surgery?
positioning, traction, division, entrapment
355
how do nerve injuries preesent
numbness, tingling, pain
356
name four wound complications after lap surgery?
seroma (MC with hernia repair), SSI, hematoma, hernia
357
What is this position
Reverse trendelenburg
358
What is this position?
Trendelenburg
