Flashcards in Last third of the doc Deck (20):
1
Why does obesity increase surgical risk?
Obesity is associated with alterations in:
Cardiovascular function
Impaired respiration
Low level systemic inflammation
Cortisol levels
2
List the organs and systems whose preoperative examination is essential from the point of view of the assessment of surgical risk!
- cardiovascular system,
- respiratory system,
- renal function,
- liver function,
- endocrine balance,
- homeostasis,
- immune system,
- metabolic state,
3
What can be applied for trombosis prophylaxis during pre-, and postoperative phase?
Drugs:
- Heparin derivatives: Na-heparin, Ca-heparin, low molecular weight heparins
- Platelet aggregation inhibitors (e.g. Aspirin and Colfarit)
- Coumarin derivatives (e.g. Syncumar)
Physical:
- early mobilization
- compression (elastic bandages)
- bed-side bicycle
- keeping the lower extremities at a high level
4
List the forms of vertical laparotomy!
Upper median laparotomy
Lower median
Middle median
Total median
Paramedian
Vertical transrectal
Pararectal
Lateral transmuscular
5
List the forms of transverse and oblique laparotomy!
Upper transverse laparotomy
Lower transverse
Paracostal
6
What abdominal approaches would you suggest in case of open cholecystectomy, appendectomy, or gynecological surgery?
Open cholecystectomy -- Right paracostal laparotomy
Appendectomy -- McBurney incision
Gynecological surgery -- Lower median muscle-splitting incision.
7
What do you know about the muscle-splitting incisions? What are the advantages and disadvantages?
Lower median muscle splitting incision, aka Pfannestie incision
Upper lateral muscle splitting incision
Lower lateral muscle splitting incision McBurney incision.
The fibers of the abdominal wall muscles are not cut but separated from each other alongside their courses.
Advantage: Postoperative hernia is rare. Disadvantage: It gives a limited exposure and is helpful only in the case of a sure diagnosis.
8
What does thoracolaparotomy mean? When it is used?
An upper transrectal or an upper transverse laparotomy running along the 7th intercostal space.
In the case of big tumors of the liver, tumors of the kidney, possibly the total gastrectomy, operations done around the cardia region, and oesophageal tumors,
When there is need to open the thoracic and the abdominal cavities simultaneously,
9
What are the disadvantages of open surgery?
• big exposure more operative trauma
• the postoperative pain depends mostly on the size of the surgical wound
• it is harmful to keep the body cavity open for a long time, vaporization and drying
• danger of secondary injuries during exposure (i.e. intestine, spleen, lung)
• the increased possibility for later adhesions
• the bigger the wound is, the higher the possibility for postoperative complications (i.e. infection, hernia, etc.)
10
What are the advantages of laparoscopic surgery?
• smaller exposure, less operative trauma
• less postoperative pain
• reduced numbers of wound infection and hernia
• less postoperative adhesions
• shorter postoperative healing period and duration of the hospitalization
• cosmetic advantages
11
What does pneumoperitoneum mean?
Insufflating the peritoneal cavity with gas to create a workspace for the laparoscopic surgeon.
12
What kind of gas can be used for pneumoperitoneum?
Carbon dioxide
-it is absorbed rapidly by the peritoneum,
-it is dissolvable in the blood,
-it is excreted rapidly from the body
-it can be used simultaneously with the electrocautery device with no danger of the explosion.
13
Introduce the usage of the Veres needle!
Used to create pneumoperitoneum with the closed access technique
Inserted blindly through the sub-umbilical area and used to create pneumoperitoneum.
Small incision 1 cm long is made intra/subumbilically. The Veress needle is checked for proper function before use.
With lifting the lower anterior abdominal wall by the left hand, introduce the Veres needle. The surgeon will be able to feel the needle piercing through the
fascia and the peritoneum separately.
The position of the needle is checked with a syringe
containing saline:
1. aspiration should yield no bowel contents, bile, blood, or gas,
2. injection of 5-10 ml of saline should meet no resistance, and
3. repeat aspiration should not withdraw the injected saline because this would have dispersed in the peritoneal cavity.
The needle is then connected to an insufflator and carbon dioxide is instilled at a pressure of 10 mmHg and with a rate of near to 1 liter/min.
After adequate insufflation (tympanic resonance), the Veress needle is removed and the pneumoperitoneum is ready for operation.
14
How and on what level of pressure can the pneumoperitoneum be used safely?
Intra-abdominal pressure is between 10-15 mmHg.
12 mmHg is ideal
It should not go beyond 18 mmHg
15-20 mmHg is suboptimal
Pressures above 20mmHg are dangerous
Collapsing veins and inhibiting venous return.
Can also cause pulmonary compromise by inhibiting diaphragm excursion.
Risk of surgical emphysema.
Risk of air embolism.
15
What type of telescope is popular in laparoscopy?
Hopkins rod lens system
the spaces between the lenses-instead of air- are filled with the glasses. This increases the light transmission, decreases the light absorption (by almost 70%) and so leads to an improvement in the quality of the picture.
16
What do you know about the laparoscopic light sources?
A 150–300 W fan-cooled xenon light source is used to provide color-corrected light for extended periods of time without overheating.
Illumination is transmitted to the laparoscope via a flexible fiber-optic light guide.
The camera is connected to the optic. It receives the arriving picture and transmit it
to the monitor.
17
List the difficulties of the laparoscopic technique!
• Two- dimensional approach and three- dimensional activity
• Eye-hand coordination
• Feeling the depth
• Coordinated use of the dominant and non-dominant hands
• Lack of the tactile sensation
• Magnified surgical territory and finer manipulations
• Fulcrum effect
• Limited movement
• New and unusual instruments
• Continuous care of the technical equipment
• Increased physical and mental demands
18
Contraindications for ambulatory surgery
poorly controlled diabetes, a history of substance abuse, patients with uncontrolled seizure disorders, susceptibility to malignant hyperthermia, potentially difficult airway, NPO < 8h, no escort, previous post –anesthetic adverse outcomes, significant drug allergies like latex, and those at risk for aspiration.
19
Bite wound in latin
Morsum
20