Laprascopic and robotic assisted surgery- part II

Question 1

The following types of surgeries can be performed laprascopically

Answer 1

gastric, colonic, splenic, hepatic, gallbladder, gynecologic, and urologic

Question 2

Relative contraindications to laparoscopic surgery includes:

Answer 2

increased ICP
hypovolemia
Severe CV disease
Severe respiratory disease
dense adhesions
V/P shunt or peritoneal jugular shunt (LaVeen)- found in abdomen

Question 3

Advantages to laparoscopic surgery includes

Answer 3

lower pain scores and opioid requirement, earlier ambulation and return to normal activities, lower incidence of post-operative ileus, faster recovery, shorter LOS, lower cost, decreased stress response, reduced postoperative pulmonary dysfunction

Question 4

Disadvantages to laparoscopic surgery include

Answer 4

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

Question 5

Laparoscopic surgery can be used for

Answer 5

diagnostic and surgical intervention

Question 6

Laparoscopic surgery uses

Answer 6

insufflation of the abdomen (carbon dioxide), views of abdominal contents through small incisions, use of small instruments through trocars, camera projects images on monitor screen, minimally invasive surgery

Question 7

A pneumoperitoneum can be created using

Answer 7

carbon dioxide (most common)
inert gases
or gasless laparoscopy (better for hemodynamically unstable patients but not commonly used)

Question 8

As compared to air, helium, oxygen, or nitrous oxide,

Answer 8

CO2 is more soluble in blood

Question 9

CO2 pneumoperitoneum is

Answer 9

non-combustible
colorless, odorless, inexpensive
eliminated via respiration
easily absorbed by the tissue (high blood solubility) with rapid elimination

Question 10

The most important aspect regarding insufflation is

Answer 10

the need to communicate with the surgeon if the patient cannot tolerate due to pulm or CV issues

Question 11

What are the respiratory effects of pneumoperitoneum?

Answer 11

reduced FRC, reduced compliance, increased ventilatory pressures, barotrauma, atelectasis

Question 12

What are the CV effects of pneumoperitoneum?

Answer 12

sympathetic stimulation= HTN, tachycardia
impaired venous return= hypotension
vagal stimulation= arrhythmias, bradycardia

Question 13

What are the renal effects of pneumoperitoneum?

Answer 13

reduced renal perfusion, activation of RAAS, increased ADH

Question 14

What are the gastric effects of pneumoperitoneum?

Answer 14

increased intra-abdominal pressure, risk of gastric regurgitation, splanchnic ischemia, embolus, extra-peritoneal spread of CO2

Question 15

The physiologic effects of pneumoperitoneum include decreased

Answer 15

Cardiopulmonary function, cardiac output, venous return, FRC, VC, and renal function

Question 16

The physiologic effects of pneumoperitoneum include increased

Answer 16

PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd (dead space), regurgitation/aspiration

Question 17

To manage the pulmonary changes with pneumoperitoneum, we can

Answer 17

degree degree of trendelenburg, modify ventilatory settings (pressure control), use PEEP with caution, consider increasing volatile, consider bronchodilators

Question 18

To manage the CV changes of pneumoperitoneum, we can

Answer 18

do slow, gradual abdominal insufflations, vent abdomen if IAP >20 mmHg, evaluate intravascular volume, consider treatment for preexisting cardiac dysfunction

Question 19

To manage the renal changes of pneumoperitoneum, we can

Answer 19

closely monitor UOP, administer IVF boluses, consider diuretics, maintain IAP <15 mmHg

Question 20

To manage the cerebral changes of pneumoperitoneum, we can

Answer 20

decrease degree of trendelenburg (adjust head up), vent abdomen if IAP >20 mmHg

Question 21

The best way to avoid CV compromise with laparoscopic surgery is

Answer 21

IAP <15 mmHg

Question 22

Invasive arterial lines should be used for patients undergoing laparoscopic surgery with

Answer 22

ASA III-IV, or abnormal PaCO2/EtCO2 gradient, for BP/serial ABGs

Question 23

The typical surgical type for laparoscopic surgery is

Answer 23

GA with cuffed ETT

RA has been used- need high block T4-5 (SNS denervation) more difficult to compensate for CV/resp changes

Question 24

The type of ventilation used for laparoscopic surgery is

Answer 24

controlled ventilation
increased MV and PIP often required
adjust RR, Vt 6-8 mL/kg, PEEP 5-10 cmH20
Goals: EtCO2= 35 mmHg, PIP, low 30s cm H20

Question 25

The benefit of doing a general with ETT for laparoscopic surgery is

Answer 25

secure airway | control of ventilation

Question 26

The benefit of using an LMA for laparoscopic surgery is

Answer 26

spontaneous ventilation, lower incidence of sore throat, lower pain scores, less analgesics, less PONV -unable to secure airway (aspiration risk), control ventilation, administer muscle relaxation

Question 27

When positioning for laparoscopic surgery, it is important to

Answer 27

prevent nerve injury- common peroneal nerve (lithotomy), & brachial plexus (shoulder braces, arm position) tilt not to exceed 15-20 degrees make changes slowly recheck ETT position after every position change fluid replacement in Trendeleburg (edema)

Question 28

Conversion to an open procedure consists of

Answer 28

supine position new fluid plan due to increased 3rd space losses new pain management plan new ventilator settings- reduce rate, increase Vt

Question 29

For the maintenance of anesthesia for laparoscopic surgery, it is important to

Answer 29

avoid nitrous oxide (could expand bowel lumen) consider propofol-based TIVA if PONV, balance techniques with volatile agent, opioids, TIVA; muscle relaxation?, careful monitoring of pulmonary and hemodynamic status, watch for ETT during position changes

Question 30

Describe the pathophysiology of a gas embolism.

Answer 30

depends on size of bubbles & rate of entrainment vapor lock in vena cava & RA, obstruction to venous return, acute RV hypertension=paradoxical embolism-> circulatory collapse

Question 31

Intraoperative complications of laparoscopic surgery includes

Answer 31

vascular injury, GI injury, cardiac, SQ emphysema, CO2 embolism

Question 32

GI injuries present during laparoscopic surgery include

Answer 32

bowel, liver, spleen, mesenteric

Question 33

Vascular injury during laparoscopic surgery is a result of

Answer 33

trocar insertion and can result in injury to the aorta, IVC, iliac vessels, cystic/hepatic arteries, retroperitoneal hematoma

Question 34

Cardiac issues that present during laparoscopic surgery include

Answer 34

dysrhythmias, increased vagal tone, BP changes

Question 35

CO2 embolism can be a result of

Answer 35

direct needle placement in vessel, gas insufflation into abdominal organ

Question 36

SQ emphysema is a result of

Answer 36

extra-peritoneal insufflation

Question 37

Capnothorax, capnomediastinum, and capnopericardium can be a result of

Answer 37

diaphragm defect, plural tear, bullae rupture

Question 38

Diagnosis of a gas embolism is via:

Answer 38

ideal world: TEE, Swan Ganz catheter, precordial doppler Real world: pulse oximetry (hypoxemia), esophageal stethoscope-Millwheel sound, sudden EtCO2 decrease, aspiration of gas from CVP, hypotension, bronchospasm, increased PIP

Question 39

Treatment of a gas embolism is:

Answer 39

``` stop insufflation and desufflate steep Trendelenburg and left lateral decubitus D/C nitrous oxide and give 100% FiO2 Hyperventilate Place CVP CPR Consider CPB ```

Question 40

Subcutaneous emphysema is a result of ____ & can be identified by

Answer 40

accidental insufflation of extraperitoneum | be aware of increases in PaCO2 after plateau has been reached

Question 41

Subcutaneous emphysema is NOT

Answer 41

a contraindication for extubation | it can track to thorax & mediastinum and result in capnothorax or capnomediastinum

Question 42

Emergence and postop considerations for laparoscopic surgery is (regrading pain)

Answer 42

intra-abdominal incisions and should pain result due to irritation of diaphragm and/or visceral pain from biliary spasm Opioids + NSAID+ Tylenol + dexamethasone + local infiltration (incisional & intraperitoneal)

Question 43

______ occurs in 40-75% of laparoscopic surgeries

Answer 43

PONV

Question 44

Robotic assisted surgery is

Answer 44

a minimally invasive surgery using "robotics" | control console, patient side cart (robotic arms), and equipment tower with screens

Question 45

Advantages to robotic assisted laparoscopy include

Answer 45

3-D view, improved depth perception & intuitive movements, increased precision 10-15x, magnification, free movement

Question 46

Disadvantages to robotic assisted laparoscopy include

Answer 46

massive system, limited working space, limited patient access, limited instrument availability, expensive, maintenance costs, longer setup

Question 47

Preparation for robotic surgery includes

Answer 47

2 peripheral IVs consider arterial line limit IVF initially (d/t Trendelenburg position) Positioning- Trendelenburg, lateral, flexion Limited access to the patient Padding- robotic can lay arms on patient concern for sliding