Jaffeexploratory Laparotomy, Hysterectomy/bso For Uterine Cancer

Front 1

Exploratory Laparotomy, Hysterectomy/BSO for Uterine Cancer
Open Technique
Laparoscopic Technique
Position

Back 1

Open Technique Supine
Laparoscopic Technique Modified dorsolithotomy in Allen stirrups

Front 2

Incision

Back 2

Open Midline longitudinal abdominal/transverse
Laparoscopic Vertical infraumbilical and multiple small transverse incisions

Front 3

Special instrumentation

Back 3

O None
L Videolaparoscopy equipment. Endoscopic GIA staplers, endoscopic ABC, endoscopic vascular clips, and CO2 laser

Front 4

Unique considerations

Back 4

O None
L Mechanical bowel preop; steep Trendelenburg

Front 5

Antibiotics

Back 5

Cefotetan 2 g iv ⇐

Front 6

Surgical time

Back 6

O 2–4 h
L 2–3 h

Front 7

Closing considerations

Back 7

O NG tube placement
L Release the pneumoperitoneum completely. Closure of fascia at trocar sites ≥ 10 mm diameter

Front 8

EBL

Back 8

O 400–750 mL
L 100–500 mL

Front 9

Postop care

Back 9

O Consider using SCDs and minidose heparin for DVT prophylaxis.
L Begin early ambulation and feeding. Patients generally can be discharged on POD 1 or 2.

Front 10

Respiratory

Back 10

[check mark]for Hx of lung disease or smoking.

Front 11

Cardiovascular Hx of CAD, HTN, or CHF Sx (e.g., angina, dyspnea, or peripheral edema) should be investigated.
Tests:

Back 11

Assess patient's exercise tolerance and current medications. Tests such as an exercise treadmill or ECHO may be indicated if patient has significant angina or CHF.
Patients > 50 yr should have a preop ECG.

Front 12

Endocrine

Back 12

Inquire about the presence of endocrine diseases, such as diabetes and hypothyroidism, which have been associated with this tumor. If the patient has received corticosteroids within the previous 6 mo, a supplemental dose of hydrocortisone (100 mg iv q 12 h × 2 d) should be considered.

Front 13

Neuromuscular

Back 13

Osteoarthritis and osteoporosis common in this patient population. Ask about NSAID usage.

Front 14

Hematologic If vaginal bleeding has been profuse or of long duration, significant
Tests:

Back 14

anemia may occur. Consider preop iron supplements if there are several days until surgery.
CBC

Front 15

Laboratory

Back 15

LFTs

Front 16

Premedication

Back 16

Consider anxiolytic, such as midazolam 1–2 mg iv. Discuss anesthetic plan and options for postop pain management with patient.

Front 17

Intraoperative
Anesthetic technique:

Back 17

ETA ± epidural or spinal analgesia/anesthesia.

Front 18

In unusual circumstances (e.g., severe lung disease), surgery may be done under

Back 18

spinal or epidural anesthesia only.

Front 19

General anesthesia:
Induction
Maintenance

Back 19

Standard induction
Standard maintenance

Front 20

Emergence
Reverse muscle relaxant with ? Consider ? prophylaxis

Back 20

neostigmine (0.07 mg/kg with glycopyrrolate 0.01 mg/kg).
PONV prophylaxis (e.g., ondansetron 4 mg iv).

Front 21

Regional anesthesia:
Epidural

Back 21

2% lidocaine (10–20 mL), ± epinephrine 1:200,000, or 0.25% bupivacaine (15–20 mL) is used; then at ~3–5 mL/h.
Narcotics, such as morphine (2–4 mg) or hydromorphone (0.3–0.6 mg), may be given in the epidural for postop pain control.

Front 22

Spinal

Back 22

Tetracaine (12–14 mg) ± preservative-free morphine (0.3–0.5 mg). Sensory level ~T5.

Front 23

Blood and fluid requirements
IV:
NS/LR at

Back 23

16–18 ga × 1
4–6 mL/kg/h

Front 24

Consider PRBC for Hct < ?
? is used for volume replacement.
If anemia is present it may be necessary to give

Back 24

25%
Crystalloid
PRBCs preop, to keep Hct > 25%.

Front 25

Monitoring Standard monitors
±

Back 25

Foley catheter
± Arterial line, CVP,NG tube Direct monitoring of arterial pressure is indicated in patients with CAD, severe HTN, or lung disease.
Consider art line and/or CVP if significant comorbidities exist.

Front 26

Positioning

Back 26

[check mark] and pad pressure points
[check mark] eyes
Antiembolism stockings and SCD

Front 27

Complications

Back 27

Hypothermia Warm iv fluids; use forced-air warmer. Heating pad on OR table.
Trauma or obstruction of ureter Watch for hematuria or ↓ UO.

Front 28

Postoperative
Complications

Back 28

PONV
VTE
Hypothermia
Bleeding See p. B-6
See p. B-7

Front 29

Pain management

Back 29

PCA (p. C-3)
Epidural/spinal narcotics (p. C-2)
Ketorolac (30 mg im/iv) is useful for breakthrough pain. A multimodal approach—including local anesthetics, NSAIDs or acetaminophen, or even low-dose (0.1–0.2 mg/kg/h) ketamine—in the OR may provide analgesia and ↓ PONV.