Laproscopic & Robotics

Question 1

What is an artificial pneumoperitoneum?

Answer 1

The installation of air or gas into the peritoneal cavity under controlled pressure

Question 2

although rare, more than 50% of all complications during laparoscopic surgery occurr during?

Answer 2

During initial surgical entry into the abdominal cavity and establishment of the pneumoperitoneum - Trocar Insertion

Question 3

what is the leading cause of morbidity and mortality during laparoscopic procedures?

Answer 3

Severe vascular injury at the time of abdominal entry

Question 4

evidence indicates that patients who are extremely _______ or______, or_________ at increased risk for laparoscopic entry related injuries at the umbilical entry point

Answer 4

Extremely thin, obese, or known to have abdominal adhesions

Question 5

what are some advantages of laparoscopic surgery over open procedures

Answer 5

-less tissue trauma(small incisions)
-better postoperative pain control (less opioids)
-superior postoperative pulmonary function
-earlier postoperative mobility
-shorter hospital stay

Question 6

Describe the “closed technique”

Answer 6

Use of a spring loaded needle (Veress needle) to pierce the abdominal wall. Trocar is blindly inserted AFTER insufflation.

Question 7

Describe the “open technique”

Answer 7

“Hasson” technique, minimize the risk of major vascular injury when creating pneumoperitoneum. A small incision up to 3 cm is made immediately inferior to the umbilicus through skin and fascia..
Insertion of trocar, then insufflation.

(studies are mixed if open is actually superior)

Question 8

How does the Hasson Trocar minimize risk of injury?

Answer 8

Two fascial suture stabilize the abdominal wall and the trocar is inserted under direct vision

Question 9

Why do we use carbon dioxide for insufflation?

Answer 9

Readily available, inexpensive, does not support combustion, rapidly absorbed from the vascular space, easily excreted by respiratory system

Question 10

What are some disadvantages to the use of carbon dioxide in laparoscopic surgery?

Answer 10

Hypercapnia-respiratory acidosis
Peritoneal and diaphragmatic irritation manifesting as postop shoulder pain

Question 11

What two hemodynamic variables increase, regardless of whether the pneumoperitoneum is created under low pressure (12mmHg) or high pressure(20mmHg)?

Answer 11

MAP and SVR

Question 12

What is the maximum pressure that can be used to maintain the inflation of the pneumoperitoneum for hours of a case?

Answer 12

15 mmHg

Question 13

How many trocar sites are usually used?

Answer 13

4-6
can be (1-6)

Question 14

At around 20-40mmHg, heart rate usually stops trending upwards. what causes the heart rate to trend down with pneumoperitoneum? How do you treat if necessary?

Answer 14

In some patients, the perennial stretch that coincides with the induction of pneumoperitoneum may stimulate a vaguely mediated bradycardia response can be relieved by releasing pressure maintained below 16 treat with anticholinergics if needed.

Question 15

True or false: positioning appears to have a greater effect on central pressures than the pneumoperitoneum itself

Answer 15

True
Steep Trendelenburg or reverse Trendelenburg influence, Venous return and cardiac output

Question 16

How does the pneumoperitoneum affect the cardiac conduction system even in healthy patients?

Answer 16

Prolonged QT dispersion in patients and undergoing laparoscopic procedure with high-pressure insufflation.
QTd reflects ventricular instability prolongation of this parameter is associated with an increased risk of arrhythmias.

[An increased QTd suggests that different parts of the heart are repolarizing at different rates, which can create an electrically unstable environment and increase the risk of cardiac arrhythmias.]

Question 17

What are some factors that influence patients response to the creation of pneumoperitoneum?

Answer 17

-length of surgery
-patient position
-patient age
-degree of intra-abdominal pressure during creation of pneumoperitoneum
-preoperative volume status
-presence of pre-existing pulmonary and or CV disease

Question 18

under normal insufflation pressures. (~15mmHg) what CV affects are seen and why?

Answer 18

Increase HR, MAP, SVR
(could see bradycardia d/t vagus nerve)

-Due to the release of Neuro endocrine hormones(vasopressin, Renin, norepinephrine, cortisol, aldosterone)
-Pressure on abdominal aorta and organs

Question 19

What is the proposed mechanism for increased abdominal pressure raising systemic, vascular resistance, causing hypertension?

Answer 19

Not completely understood, but thought to involve compression of the aorta or intra-abdominal resistance arterioles

Question 20

Distention of the abdominal wall viscera, especially patients with high vagal tone in young women predisposes them to vagaly mediated reflexes such as:

Answer 20

Bradycardia and bronchospasm

Question 21

Increased intra-abdominal pressure displace is the diaphragm in a cephalad direction. What does this do to functional residual capacity and V/Q matching

Answer 21

Reduced FRC and predisposes to V/Q mismatching

Question 22

Increased intra-abdominal pressure could have what effect on your ET tube?

Answer 22

Displace the carina cephalad, which predisposes to inadvertent mainstem bronchial intubation

Question 23

Just because laparoscopic procedures are minimally invasive that does not mean they are minimal _____

Answer 23

Risk

Question 24

What sort of hemodynamic changes should you expect in the elderly patient undergoing a laparoscopic surgery

Answer 24

Exaggerated hemodynamic responses compared to healthy younger patients
Moderate decreases in CO
Increased afterload and CVP, but decrease MAP

Question 25

what capacities or volumes are reduced due to the effects of pneumoperitoneum

Answer 25

-Decreased forced vital capacity (FVC) -Dec. forced expiratory volume in one second(FEV1), and -Dec. functional residual capacity (FRC) Creating areas of atelectasis in making ventilation difficult

Question 26

How does Positive Inspiratory Pressure (PIP) change with pneurmoperitoneum?

Answer 26

Increased

Question 27

Increased PaCO2 and etCO2 from the carbon dioxide insufflation can cause?

Answer 27

acidosis Characterized as respiratory acidosis.

Question 28

How does pulmonary compliance change with insufflation?

Answer 28

Decreases (less change in volume / change in pressure)

Question 29

What are peak plateau pressures? When are they measured?

Answer 29

Relationship between volume and compliance. Is a reflection of lung compliance. Reflects the pressure. It takes to hold a given volume inside the lungs. Measured during end inspiration

Question 30

How would you expect venous return to change with reverse Trendelenburg position?

Answer 30

Reduces venous return which may lead to a fall in cardiac output and arterial pressure

Question 31

Steep Trendelenburg position decreases Venus return from the head, which can result in?

Answer 31

Increase intracranial and intraocular pressures Venus engorgement of face and neck

Question 32

What position would you expect to put a patient in for a laparoscopic appendectomy?

Answer 32

Trendelenburg

Question 33

In Trendelenburg position by about what percent does pulmonary compliance and peak Plateau pressures change?

Answer 33

Pulmonary compliance decreased by ~ 50% Peak plateau pressures increased by ~50%

Question 34

How do you expect to position a patient for a laparoscopic Cholecysectomy? How do you expect functional residual capacity in venous return to change?

Answer 34

Reverse Trendelenburg Increase FRC Decrease Venous Return

Question 35

How do you expect etCO2 to change during laparoscopy?

Answer 35

Increase. CO2 used for insufflation of the abdomen, is highly soluble and will dissolve across tissues into the bloodstream.

Question 36

Will etCO2 reflect PaCO2 during laparoscopy?

Answer 36

Unlikely. etCO2 will often still UNDERestimate the arterial CO2 by as much as 10mmHg

Question 37

Renal effects of pneumoperitoneum?

Answer 37

-transient increase in creatinine clearance -decreased urine output due to decreased renal blood flow, release of ADH, and PACO2 levels, create a sympathetic response leading to renal vasoconstriction

Question 38

Hepatic and Splanchnic Effects of pneumoperitoneum

Answer 38

Decrease in splanchnic and liver perfusion -intestinal ischemia

Question 39

immunological effects of pneumoperitoneum

Answer 39

*Controversial* -influences growth of human cancer cells -pressure dependent Controversial

Question 40

What three major organs could be damaged during umbilical entry for laparoscopic procedures?

Answer 40

Bladder, bowel, uterus

Question 41

Name the top three complication/injuries that can occur when performing laparoscopic procedure procedures

Answer 41

1. 50% of vascular injury upon entry into abdomen with trocar 2. Visceral injuries, particularly intestinal. 3. Urinary tract injury.

Question 42

the migration of gas to create the pneumoperitoneum can result in what complications?

Answer 42

-Pneumothorax -Pneumomediastinum -Pneumopericardium -Subcutaneous emphysema -Gas embolism

Question 43

While mortality and the incident is rare, how often does gas embolism occur during laparoscopic procedures?

Answer 43

Studies using TEE show that actual incident of gas embolism maybe between 65 to 100% -however, most are very small and don't create a problem

Question 44

What are some signs of gas embolism?

Answer 44

Hypotension Hypoxemia Dysrhythmias "mill-wheel" murmur Wheezing Decreased SPO2 Pulmonary edema Abrupt decrease in ETCO2

Question 45

Treatment of gas embolism:

Answer 45

-100% 02 -Release pneumoperitoneum -Stop nitrous oxide if using -Flood filled with NS -Left lateral decubitus position (Durant Maneuver) -Aspirate CVP line -Supportive measure measures

Question 46

Subcutaneous emphysema has an increased incident when?

Answer 46

The insufflator has high gas, flow and high gas pressure settings -abdominal pressure greater than 15 mmHg -multiple attempts at abdominal entry -Veress needle, or cannula not placed in peritoneal cavity -skin or seal around cannula is not snug -use of more than five cannulas -procedures lasting longer than 3.5 hours -etCO2>50mmHg

Question 47

Signs of subcutaneous emphysema

Answer 47

-late hypercarbia -decreased lung compliance -increase CO2 absorption, increased ET CO2 above 50 -cardiac arrhythmias, tachycardia, hypertension -crepitus around abdomen chest, neck or groin

Question 48

Management of sub Q emphysema

Answer 48

-Evaluate for pneumothorax -check, etCO2 CO2 and arterial CO2 -increase, ventilation rate entitled volume (Ve) -increase oxygen to 100% -check CO2 absorber in circuit -decrease inter-abdominal pressure -d/c N2O if in use -assess airway to ensure there is no compression before extubating

Question 49

Shoulder pain is due to insufflation, pushing up on the diaphragm, causing which nerve to be irritated? When does it usually resolve?

Answer 49

phrenic nerve Normally resolve spontaneously in one to two days

Question 50

What type of anesthesia is usually used for laparoscopic cases?

Answer 50

General anesthesia most common with ETT

Question 51

What ventilator setting is usually preferred during laparoscopic cases?

Answer 51

Pressure controlled ventilation Able to use recruitment maneuvers and add peep

Question 52

Describe the recruitment maneuver an anesthesia provider could use via the ventilator during a laparoscopic case?

Answer 52

Apply pressures of 35-40cmH2O x40s to inflate alveoli. Apply PEEP after this maneuver

Question 53

Can you use an LMA for Laparoscopy?

Answer 53

Controversial. Depends on type of surgery, body habits, and aspiration factors. Most advantageous LMA: ProSeal LMA

Question 54

PONV is as high as ___% in laparoscopic surgery

Answer 54

72%

Question 55

PONV post laparoscopic surgery is associated with?

Answer 55

-Surgical wound dehiscence -Aspiration -Unanticipated hospital admission

Question 56

For higher risk PONV patients what might be your anesthetic management plan for a laparoscopic case?

Answer 56

TIVA combined with anti-emetics

Question 57

What drugs can cause the Sphincter of Oddi to spasm?

Answer 57

Morphine (meperidine as well)

Question 58

What are some anesthetic considerations when working a robotic surgery case?

Answer 58

-prolonged surgical times -spatial restrictions -inability to alter patient position after "docking" -physiological changes d/t extreme positioning -risk of postop visual loss -physiological changes related to pneumoperitoneum -implementation of ERAS protocol

Question 59

In steep Trendelenburg (40-45 degree head down tilt), what are some CV changes you expect?

Answer 59

Increased MAP, CVP, SVR, PAOP

Question 60

In steep Trendelenburg (40-45 degree head down tilt), what are some respiratory changes you expect?

Answer 60

Increased: airway resistance, peak pressure, plateau, pressure, ETC O2, upper airway edema Decreased: Lung compliance, vital capacity, FEV1

Question 61

In steep Trendelenburg (40-45 degree head down tilt), what are some cerebrovascular changes you expect?

Answer 61

Increase: ICP, hydrostatic pressure gradient, cerebral vascular resistance Decrease: Cerebral venous drainage

Question 62

Effects of increased systemic CO2

Answer 62

Respiratory Acidosis Arrhythmias Cerebral Vascular Dilation: inc. ICP

Question 63

How might the oxy – hemoglobin dissociation curve change during laparoscopic procedures?

Answer 63

Shift to the Right via the Haldane Effect. Helps deliver oxygen to the tissues and results and slightly less ischemia than would be expected.

Question 64

What are some anesthetic management considerations for a patient in steep Trendelenburg?

Answer 64

-keep patient paralyzed -OG/NG to decompress stomach -limit fluids (facial edema) -pulse oximeter placement -prolonged pressure on back of scalp

Question 65

What drugs can be used to reverse a spasm of the sphincter of Oddi? (pick2) A. Flumazenil B. Naloxone C. Glucagon D. Neostigmine

Answer 65

B. Naloxone - opioids are a common cause of sphincter of oddi spasm C. Glucagon - a hormone produced by the pancreas, has several effects on the body, including smooth muscle relaxation. Can also stimulate release of bile from the gallbladder.

Question 66

The initial insulation of a pneumoperitoneum results in which adverse cardiopulmonary effect? A: hypercarbia and acidosis B. increased V/Q mismatch. C. Decreased SVR. D. increased cardiac output.

Answer 66

B. increased V/Q mismatch.

Question 67

Which G.I. effects can occur patients who receive a thoracic epidural compared with those who do not receive a thoracic epidural for postoperative analgesia after major inter-abdominal/intrathoracic surgeries? A. Dec gastric secretions D. increased duration of ileus C. increased peristalsis D. sphincter contraction

Answer 67

Increased peristalsis due to unopposed parasympathetic activity.

Question 68

What is considered the best diagnostic technique for assessing for abdominal compartment syndrome?

Answer 68

intravesicular (BLADDER) pressure measurement

Question 69

When does abdominal compartment syndrome (ACS) develop?

Answer 69

An intra-abdominal pressure greater than 20mmHg With or without an abdominal perfusion pressure less than 55mmHg (MAP - IAP) and evidence of decreased organ perfusion

Question 70

During a laparoscopic procedure what are the effects on cerebral volume and pressure?

Answer 70

Increased intracranial pressure and decrease cerebral venous return

Question 71

Renal blood flow and GFR can decrease by how much during abdominal insufflation?

Answer 71

By 25%

Question 72

Which statement is most accurate regarding inhale nitrous oxide as part of a balanced anesthetic for electroscope lasting greater than one hour? A. contraindicated due to risk of tension pneumo B. it can have an effect on surgical visualization. C. Likelihood of combustion and abdomen goes up greatly. D. it should be avoided, regardless of surgical duration.

Answer 72

B. it can have an effect on surgical visualization. Can lead to complex surgical visualization and prolonged procedures greater than 60 minutes due to intestinal/colonic distention, which may obstruct surgical visualization, decrease intestinal, contractility, and increase the risk of intestinal leakage and anastomotic breakdown.

Question 73

What immediate step should be taken if crepitus from CO2 insufflation is identified intra-operatively? (select 2) A. assess for the presence of capnothorax B. turn to left lateral to cubitus with Trendelenburg. C. Discontinue positive and expiratory pressure. D. deflate the peritoneum as soon as possible.

Answer 73

A and D