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Anesthesia Principles I > Test 2 Laproscopy and Robotic Surgery > Flashcards

Test 2 Laproscopy and Robotic Surgery Flashcards

1
Q

what surgery was the first to be done laproscopically?

A

cholecystectomy

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2
Q

common surgeries where laparoscopic and robotic techniques are used

A
  1. general surgery
  2. gynecologic surgeries
  3. urologic
  4. orthopedic - specifically arthroscopy
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3
Q

benefits to minimally invasive surgery?

A
  1. smaller incisions
  2. less postop pain
  3. decreased incisional stress response 4. decreased rate of complications
  4. faster recovery
  5. decreased LOS
  6. overall improved pt satisifaction
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4
Q

Disadvantages of minimally invasive surgeries

A
  1. sequela of pneumoperitoneum
  2. positioning challenges
  3. need for specialized training
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5
Q

laparoscopic surgery requires the creation of an artificial pneumoperitoneum, this done by?

A

instillation of air/gas into a cavity under controlled pressure

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6
Q

what are the two most commonly used entry methods in lap surgery to create a pneumoperitoneum

A
  1. closed technique
  2. open (hasson) technique
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7
Q

what gas is used to insufflate the peritoneal cavity during lap surgery to allow visualization of the organs

A

CO2

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8
Q

why is CO2 the gas of choice for insufflation during laproscopic surgery?

A
  1. non toxic
  2. nonflammable
  3. readily absorbed into the blood stream with minimal risk of air embolization
  4. produces less hemodynamic effects than other nonflammable gases (argon)
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9
Q

during laparosocpic surgery, when insufflating CO2 for creation of pneumoperitoneum, the intra-abdominal pressure needs to be limited to ________ mmHg

A

15

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10
Q

describe the closed technique for creating pneumoperitoneum during lap surgery

A

use spring loaded needle - veress needle to pierce abdominal wall at thinnest point around the umbilicus

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11
Q

describe the open technique to create a pneumoperitoneum during laparoscopic surgery

A

make 1 - 2.5 mm midline vertical incision that begins at the lower boarder of the umbilicus and extends through the subQ tissue and underlying fascia

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12
Q

what part of laparoscopic surgery is responsible for the large majority of complications that occur?

A

creation of the pneumoperitoneum

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13
Q

the creation of a pneumoperitoneum for laparoscopic surgery causes increased intrabdominal pressure, what effect does this have on CV/hemodynamics?

A
  1. increase: SVR, MAP, and HR
  2. decrease: SV
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14
Q

physiological effects of pneumoperitoneum depend on what factors?

A
  1. degree of intra-abdominal pressure 2. length of surgery
  2. patient position
  3. perioperative volume status
  4. patient age
  5. presence of co-morbidities, esp cardiopulmonary ones.
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15
Q

CV effects of pneumoperitoneum (for laparoscopic surgery)

A
  1. variable effects on cardiac filling pressures
  2. CO reduction of 20-50%
  3. SV reduction secondary to increased IAP
  4. CO2 absorption can cause myocardial depression/arrhythmias
  5. has effect on cardiac conduction system
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16
Q

how can you decrease CO reduction with pneumoperitoneum?

A

adequate fluid load and compression stockings prior to surgery

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17
Q

how can you ensure stroke volume is not reduced with pneumoperitoneum (for lap surgery)?

A
  1. adequate perioperative hydration
  2. changes in patient position
  3. application of compression stockings
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18
Q

what has the greater effect on cardiac filling pressures during laparoscopic surgery - the pneumoperitoneum or positioning?

A

positioning

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19
Q

during laproscopic surgery, what position will increase CVP, ICP, IOP and cause head/airway edema?

A

trendelenburg

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20
Q

during laparoscopic surgery, what position will reduced cardiac preload; therefore, reducing CO

A

reverse trendelenburg

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21
Q

with creation of pneumoperitoneum for laparoscopic surgery, CO2 absorption that makes PaCO2 > 60, will cause what effect on the CV system?

A

myocardial depression and arrhythmias

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22
Q

with creation of pneumoperitoneum, CO2 absorption –> PaCO2 45-60, will have what effect on the CV system?

A

little CV effect

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23
Q

high pressure insufflation of pneumoperitoneum can lead to what cardiac conduction changes?

A
  1. prolong QT dispersion = ventricular instability –> increased arrhythmias and cardiac effects
  2. bradycardia
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24
Q

how does laparoscopic surgery/pneumoperitoneum affect the respiratory lung mechanics?

A
  1. decrease compliance
  2. decrease FVC
  3. decrease FEV1
  4. decrease FRC
  5. increase PIP
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25
Q

how does the pneumoperitoneum/laparoscopic surgery affect gas exchange?

A
  1. increases PaCO2 and EtCO2
  2. subcutaneous tracking of CO2 d/t misplaced trocars
  3. V/Q mismatch
  4. hypoxemia
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26
Q

if a patient is undergoing laparoscopic surgery, and their EtCO2 starts to rise, what action must you take to offset the hypercarbia?

A

increase minute ventilation

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27
Q

hypercarbia with laparoscopic surgery will hit its peak at ~ ________ minutes

A

40

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28
Q

maximum absorption of CO2 with laparoscopic surgery occurs when IAP is __________ mmHg

A

10

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29
Q

laparoscopic surgery, can cause displacement of abdominal structures which can have what effects on the respiratory system?

A
  1. atelectasis
  2. possiblity for endobronchial intubation
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30
Q

________________ is necessary to maintain normocarbia in the anesthetized patient undergoing laparoscopic surgery with CO2 pneumoperitoneum

A

controlled mechanical ventilation

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31
Q

what vent settings do you want when your patient is undergoing laparoscopic surgery with pneumoperitoneum

A
  1. increase minute ventilation by 20-30%
  2. pressure control
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32
Q

lung protection strategies on the ventilator with laparoscopic surgery with pneumoperitoneum

A
  1. 6-8 mL
  2. 6-8 cmH20 PEEP
  3. intraoperative recruitment maneuvers q30min
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33
Q

T/F: mild pulmonary dysfunction is normal after laparoscopic surgery with pneumoperitoneum

A

TRUE

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34
Q

post-op laparoscopic surgery patients will have a slight ______________ breathing pattern d/t residual effects of anesthesia, pain, and diaphragmatic dysfunction

A

restrictive

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35
Q

who is at increased risk of respiratory decompensation with laparoscopic surgery

A
  1. pts with marginal cardiopulmonary function
  2. COPD
  3. Morbidly obese
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36
Q

renal effects with laparoscopic surgery

A
  1. transient increase Cr clearance
  2. decreased UOP
  3. increased release of ADH, aldosterone, and renin
  4. renal vasoconstriction
  5. decreased renal blood flow
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37
Q

hepatic and splanchnic effects of laparoscopic surgery/pneumoperitoneum

A
  1. decreased liver and splanchnic blood flow
  2. 50% of pts will have increased liver enzymes
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38
Q

immunologic effects of laparoscopic surgery + pneumoperitoneum

A
  1. negative effect on local immune response
  2. altered levels of proinflammatory cytokines and angiogenic factors
  3. potential cancer cell growth
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39
Q

complications with laparoscopic surgery occurs in _____-_____%

A

0.3 - 1

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40
Q

more than 50% of all laparoscopic surgery complications occur when?

A

during entry into the abdomen and insertion of trocars

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41
Q

what percentage of abdominal entry/trocar insertion injuries go unrecognized/undiagnosed ?

A

30-50%

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42
Q

entry related complications with laparoscopic surgery involve: __________, ____________, ____________, and ____________

A

intestinal tract; urinary tract; vascular injuries; CO2 gas embolism

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43
Q

with laparoscopic insertion injury that causes major bowel or vascular injury, the mortality rate is ___________%

A

30

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44
Q

risk factors that increase the risk of laparoscopy complications/injuries

A
  1. body habitus and position
  2. anatomic anomalies
  3. prior surgery
  4. surgeon skill
  5. degree of abdominal elevation during trocar placement
  6. volume of gas insufflation
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45
Q

> _____________% of intestinal injuries with laparoscopic surgery are unrecognized intraoperatively

A

50

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46
Q

patients who experience intestinal injury during laparoscopic surgery, that goes unrecognized can result in?

A
  1. peritonitis
  2. sepsis
  3. respiratory distress
  4. Multisystem organ failure
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47
Q

what technique is associated with lower incidence of unrecognized vascular and visceral injury during laparoscopic surgery

A

open (Hasson) entry

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48
Q

injury to the intestines during laparoscopic surgery occurs in __________% of surgeries

A

0.3-0.5

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49
Q

urinary tract injuries during laparoscopic surgery occur in ____________% of surgeries

A

0.5-0.8

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50
Q

urinary tract injuries during laparoscopic surgery typically occur secondary to ?

A
  1. trauma from instrument manipulation
  2. electrocautery
  3. laser
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51
Q

how can you decrease the risk of urinary tract injuries during laparoscopic surgery?

A

insert foley catheter and instill methylene blue dye

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52
Q

T/F: urinary tract injuries are easily recognized during laparoscopic surgery

A

true (will have urine leakage from damaged structure)

53
Q

placement of primary trocar under ________ creates the safest distance between the anterior abdominal wall and underlying abdominal contents to minimize injury from placement

A

high pressure - 25 mmHg

54
Q

what is a complication that occurs during laparoscopic surgery that involves the direct entrainment of air/medical gas into the arterial/venous system

A

CO2 gas embolisms

55
Q

T/F: CO2 gas embolism during laparoscopic surgery is rare, but has a mortality rate of 28%

A

TRUE

56
Q

the erroneous placement of a veress needle/trocar directly into intrabdominal vessel can cause what complication

A

CO2 embolisms

57
Q

CO2 embolism with laparoscopic surgery can occur anytime there are open vessels that have ______________ < ___________

A

intravascular pressure < intraabdominal pressure

58
Q

T/F: most laparoscopic cases have minor CO2 gas embolisms which cause cardiopulmonary changes, but they resolve spontaneously

A

TRUE

59
Q

s/sx of significant gas embolism during laparoscopic surgery in the anesthetized patient:

A
  1. acute decrease/loss of EtCO2 and Increase in EtN2
  2. Hypotension and/or hypoxia that is unexplained
  3. tachycardia
  4. dysrhythmias
  5. severe hemodynamic instability
  6. CV collapse
60
Q

Dx of CO2 gas embolism during laparoscopic surgery

A
  1. TEE
  2. doppler mill wheel murmur (w/ 0.5 mL/kg of gas - late sign)
61
Q

what is the most sensitive diagnostic tool for dx a CO2 gas embolism with laparoscopic surgery

A

TEE

62
Q

CO2 gas embolism management during laparoscopic surgery

A
  1. D/C insufflation
  2. D/C N2O
  3. 100% FiO2
  4. flood surgical field with saline to halt gas entrainment
  5. left lateral position
  6. gas aspiration via central line if in place
  7. support hemodynamics with volume and vasopressors
63
Q

T/F: high CVP increases the risk of venous gas embolisms

A

false; low CVP increases the risk

64
Q

pneumomediastinum/thorax/pericardium is rare, but occurs most commonly during laparoscopic _____________ surgery

A

esophageal

65
Q

a rare, but serious complication with laparoscopic surgery is _________________________ that occurs d/t migration of gas into adjacent body cavities

A

pneumomediastinum/thorax/pericardium

66
Q

how does a pneumomediastinum/thorax/pericardium occur with laparoscopic surgery

A

gas can enter the thoracic cavity through:
1. congenital defects in the diaphragm 2. embryonic connections btween thorax and abdomen
3. perforation in the diaphragm or pleura

67
Q

T/F: pneumothorax caused by CO2 insufflation during laparoscopic surgery is usually self resolving

A

TRUE

68
Q

if during laparoscopic surgery, a pneumothorax occurs from barotrauma (like ruptured pulmonary bleb), how should it be treated?

A

surgical needle decompression followed by chest tube placement

69
Q

risk factors for pneumothorax w/ laparoscopic surgery

A
  1. esophageal surgery
  2. surgery time > 200 minutes
  3. EtCO2 > 50 mmHg
  4. operator inexperience
70
Q

s/sx of pneumothorax (with lap surgery)

A
  1. increased PIP
  2. decreased O2 sat
  3. absence of breath sounds
  4. hypotension
  5. tachycardia
  6. CV collapse
71
Q

___________________ is a frequent manifestation of pneumoperitoneum d/t gas entry into fat tissue

A

Subcutaneous emphysema

72
Q

subcutaneous emphysema with pneumoperitoneum will usually resolve itself within __________ hours

A

24

73
Q

what has been associated with causing subQ emphysema in patients undergoing laparoscopic surgery with pneumoperitoneum

A
  1. misplacement of veress needle/trocar into subQ 2. high intraabdominal pressures and movement of gas through peritoneal defects
74
Q

severe cases of subQ emphysema, secondary to pneumoperitoneum have been associated with the development of what?

A
  1. severe hypercarbia
  2. decreased chest compliance
  3. hemodynamic instability
75
Q

what properties would be required for an ideal gas in the creation and maintenance of pneumoperitoneum

A
  1. colorless
  2. inflammable
  3. physiologically inert
  4. pulmonary excretion
76
Q

why can N2O and air not be used as gas for creation and maintenance of pneumoperitoneum?

A

support combustion and cannot be used in the presence of electrocautery (which is essential for lap)

77
Q

why can helium not be used as gas for the creation and maintenance of pneumoperitoneum

A

highly insoluble which raises issues in safety in the presence of significant gas embolism

78
Q

pros of CO2 as “ideal gas” for creation and maintenance of pneumoperitoneum?

A
  1. readily available and inexpensive
  2. does not support combustion
  3. high solubility
  4. pulmonary excretion
79
Q

cons of CO2 as “ideal gas” for creation and maintenance of pneumoperitoneum

A
  1. prolonged CO2 can cause hypercarbia and respiratory acidosis
  2. is a peritoneal/diaphragmatic irritant
80
Q

CO2 use with pneumoperitoneum is a peritoneal/diaphragmatic irritant that has been associated with causative factor in the development of ____________________

A

postoperative shoulder pain

81
Q

what type of anesthetic technique can be used with laparoscopic surgery

A

local, regional, and general

82
Q

what is the most common anesthetic technique used with laparoscopy?

A

general

83
Q

with laparoscopic surgery, on the ventilator, ________________ is increased by 15-30% to offset ___________

A

minute ventilation; CO2 absorption

84
Q

what ventilator mode is most effective during laparoscopic surgery

A

pressure control

85
Q

neuraxial anesthesia (SAB and epidural) are usually reserved for laparoscopic ______________ procedures

A

pelvic

86
Q

pros of neuraxial anesthesia (SAB and epidural) with laparoscopic surgery

A
  1. decreased stress response
  2. early ambulation with lower DVT rates
  3. effective post op pain control
87
Q

disadvantages of neuraxial anesthesia with laparoscopic surgeries

A
  1. high sensory levels required which may result in: pain, hypotension, and respiratory compromise
  2. can be difficult d/t pneumoperitoneum and positioning
88
Q

PONV with laparoscopic surgery is VERY high (72%); therefore, how should you approach this?

A
  1. different drugs with different targets 2. Consider TIVA
89
Q

emergence and postoperative concerns of patients undergoing laparoscopic surgery?

A
  1. assess for SubQ air
  2. assess for facial/airway edema (check cuff leak)
  3. multimodal PONV
  4. multimodal pain management
90
Q

what multimodal pain approach should you take postoperatively for patients undergoing laparoscopic surgery?

A
  1. ERAS (enhanced recovery after major surgery)
  2. NSAIDs
  3. Glucocorticoids
  4. local anesthesia
91
Q

anesthetic technique with laparoscopic cholecystectomy

A

GETA with NMB

92
Q

what position is the patient in during laparoscopic cholecystectomy?

A
  1. reverse trendelenburg 2. left tilt
93
Q

what laparoscopic techniques can be used for cholecystectomy?

A
  1. traditional 2. robotic assisted
94
Q

anesthetic technique with laparoscopic appendectomy?

A

GETA with NMB

95
Q

positioning with laparoscopic appendectomy

A
  1. trendelenburg
  2. L tilt
  3. L arm tucked at side
96
Q

anesthesia considerations with laparoscopic appendectomy

A
  1. hemodynamic stability - tachycardia 2. volume status
  2. febrile?
97
Q

laparoscopic techniques with appendectomy

A

traditional & robotic assisted

98
Q

indication of laparoscopic nissen fundoplication?

A
  1. GERD
  2. hiatial hernia
  3. barretts esophagus
99
Q

anesthetic technique with laparoscopic nissen fundoplication

A
  1. GETA with NMB
  2. RSI and intubation
  3. PONV prophylaxis
100
Q

what must the anesthesia provider avoid during laparoscopic nissen fundoplication surgery

A

NOTHING IN ESOPHAGUS (OGT, esophageal stethoscope, temp probes)

101
Q

laparoscopic nissen fundoplication surgeries have a high risk for ________________

A

pneumothorax

102
Q

positioning with laparoscopic nissen fundoplication

A

combination of supine and lithotomy

103
Q

laparoscopic technique with nissen fundoplication

A

traditional and robotic assisted

104
Q

indication for a laparoscopic adrenalectomy?

A

pheochromocytoma

105
Q

anesthesia considerations with laparoscopic adrenalectomy

A
  1. alpha blockade prior to beta
  2. ABP monitoring
  3. IV access
  4. vasoactive meds
106
Q

anesthetic technique during laparoscopic adrenalectomy

A
  1. GETA with NMB
  2. multimodal pain management
107
Q

what position will a patient undergoing a laparoscopic adrenalectomy be in

A

lateral

108
Q

laparoscopic techniques for adrenalectomy

A

traditional or robotic assisted

109
Q

anesthetic technique with laparoscopic hysterectomy

A
  1. GETA with NMB
110
Q

positioning with laparoscopic hysterectomy

A
  1. steep trendelenburg
  2. low lithotomy
  3. with arms tucked at side
111
Q

laparoscopic techniques with hysterectomy

A
  1. traditional
  2. robotic assisted
  3. combo with vaginal/open procedure
112
Q

anesthetic technique with laparoscopic gastric bypass surgery

A

GETA with NMB

113
Q

anesthetic considerations with laparoscopic gastric bypass

A
  1. could be difficult airway –> RSI
  2. placement of esophageal dilator/bougie per surgeon request
  3. NOTHING IN ESOPHAGUS
  4. morbidly obese and positioning considerations
  5. airway/ventilation/oxygenation concerns
  6. ERAS
  7. PONV prophylaxis
  8. Pain management
114
Q

pros of minimally invasive robotic surgery

A
  1. improved patient outcomes
  2. decreased LOS
  3. faster recovery
  4. reduced perioperative blood loss
  5. reduced postoperative pain
115
Q

anesthetic implications of robotic assisted surgery

A
  1. prolonged surgical times
  2. spatial restrictions associated with robot
  3. inability to alter patient position after docking
  4. physiologic changes associated with extreme positioning
  5. physiologic consequences associated with pneumoperitoneum
  6. risk of POVL
  7. implementation of ERAS
116
Q

what is the most common position used with minimally invasive robotic surgeries

A

trendelenburg

117
Q

positioning considerations with minimally invasive robotic surgery

A
  1. prolonged surgery = prolonged pressure
  2. potential for compression of underlying structures: face and chest 3. patient sliding - 2ndary gravitational forces
118
Q

how often does patient position need to be assessed during minimally invasive robotic surgery

A

every 15 minutes

119
Q

what is the most common robotic assisted procedure?

A

robotic assisted laparoscopic prostatectomy (RALP)

120
Q

anesthetic technique with robotic assisted laparoscopic prostatectomy?

A

GETA with NMB

121
Q

patient position with robotic assisted laparoscopic prostatectomy (RALP)?

A

steep trendelenburg + lithotomy

122
Q

what is the most common nerve damaged during robotic assisted laparoscopic prostatectomy?

A

common peroneal

123
Q

risks/complications with RALP ?

A
  1. venous air embolisms if insufflation pressure > venous pressure (in presence of active bleeding)
  2. increased ICP
  3. POVL
124
Q

which cardiac surgeries can be done robotically?

A
  1. TECAB (total endoscopic coronary artery bypass)
  2. MVR (mechanical valve replacement) 3. ASD
  3. Ablation atrial arrhythmias
125
Q

anesthetic technique during robotic cardiac surgery

A

GETA with NMB

126
Q

position with robotic cardiac surgery

A

modified L or R lateral position

127
Q

what is the monitoring with required with robotic cardiac surgery

A

continuous TEE and invasive monitoring

128
Q

what is challenge for anesthesia providers during robotic cardiac surgeries?

A

maintained prolonged one lung ventilation

Anesthesia Principles I (5 decks)

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