Jaffelaparoscopic Surgery In Gynecologic Oncology

Front 1

Position
Incisions

Back 1

Dorsal lithotomy; legs in Allen universal stirrups; steep Trendelenburg
Intraumbilical; bilateral suprapubic; midline suprapubic

Front 2

Special instrumentation

Back 2

CO2 laser; bipolar Kleppinger forceps; suction irrigator; may require Harmonic Scalpel; various laparoscopic stapling instruments

Front 3

Unique considerations

Back 3

Extended operative time and period of abdominal insufflation for radical procedures. Possible rapid need for laparotomy. Extensive use of electrocautery, ABC, CO2 laser

Front 4

Antibiotics
Surgical time

Back 4

Cefazolin 1 g or cefotetan 2 g iv
1.5–5 h

Front 5

Closing considerations

Back 5

Quicker than with laparotomy; but fascia of all 10- to 12-mm ports need to be closed. Five mm trocar sites can be closed in a subcuticular fashion.

Front 6

EBL
Postop care

Back 6

50–1500 mL, depending on extent of procedure
Clear liquid diet; ambulate POD 1

Front 7

Anesthetic Considerations
(Procedures covered: laparoscopic surgery for endometriosis, ectopic pregnancy, myomectomy, hysterectomy)
Preoperative
Respiratory

Back 7

There can be intraop respiratory compromise from ↑ intra-abdominal pressure 2° CO2 insufflation; however, patients without significant respiratory disease tolerate the insufflation quite well.
Tests: As indicated from H&P.

Front 8

Cardiovascular Insufflation of the abdomen (typically with pressures of 14–22 mmHg) ↑↑

Back 8

↑↑ SVR and ↓ venous return. ↑ PaCO2 →↑ dysrhythmias. These are usually well tolerated in the otherwise healthy patient.
Tests: As indicated from H&P.

Front 9

Gastrointestinal Patients often have a mechanical bowel prep the night before.

Back 9

Check for Sx of dehydration (↓ skin turgor, orthostatic ↓ BP, ↑ HR, etc.) and hypokalemia (e.g., weakness, flattened T waves, dysrhythmias, etc.). The combination of ↑ intra-abdominal pressure + Trendelenburg position →↑ aspiration risk.
Test: Electrolytes

Front 10

Hematologic

Back 10

These patients often are having surgery for abnormal uterine bleeding → consider anemia.
Test: Hct

Front 11

Premedication

Back 11

Consider midazolam 1–3 mg iv

Front 12

Intraoperative
Anesthetic technique:

Back 12

GETA
Induction Standard induction (see p. B-2). Rapid sequence induction (see p. B-4) usually is indicated for patients with an ectopic pregnancy. OGT/NGT to decompress stomach prior to surgery start.
Maintenance Standard maintenance (see p. B-2). Muscle relaxation helpful for initial trocar insertions and may be helpful throughout procedure.
Emergence Standard emergence

Front 13

Blood and fluid requirements Usually minimal blood loss
IV: 18 ga × 1
NS/LR @

Back 13

2–6 mL/kg/h Before induction, these patients may need extra fluid 2° dehydration if given mechanical bowel preparation. During surgery, large volumes of fluid are sometimes given intra-abdominally for irrigation and hydrodissection → fluid overload; therefore, carefully account for all fluids, and titrate iv fluids to maintain euvolemia.

Front 14

Monitoring
.

Back 14

Standard monitors (see p. B-1).
Foley catheter

Front 15

Complications Bradydysrhythmias Attributed to

Back 15

peritoneal or fallopian-tube stimulation. Rx: stop surgery; deflate pneumoperitoneum; administer atropine 0.5 mg or glycopyrrolate 0.4–0.6 mg.

Front 16

Complications

Back 16

Bleeding
Hypothermia Vascular puncture a rare risk with trocar insertion. 2° the large volume of fluid and CO2 infused into the abdomen and lithotomy position. Consider warming iv fluids and use of forced-air warming device.
Extra-abdominal insufflation Occasionally, the insufflating gas can enter a vein, hollow viscera, subcutaneous tissue, thorax, mediastinum, or pericardium. Fortunately, since the gas is usually CO2, small volumes are absorbed quickly and usually do not cause major physiologic compromise; however, large volumes may → cardiopulmonary collapse (e.g., 2° pneumothorax, VAE). Subcutaneous air can compromise the airway in some cases. [check mark] airway before extubation.
Neuropathies These can be long cases, with the patient in lithotomy position. Make sure the pressure points are padded well and, if the arms are out, relieve stress on the brachial plexus.
Fluid overload [check mark] fluid volume entering and exiting the abdomen. Fluid absorption → fluid overload → CHF, edema.
P.856

Front 17

Postoperative
Complications

Back 17

PONV
VTE
Hypothermia →↑ Risk for PONV. See p. B-6.
See p. B-7.

Front 18

Pain management

Back 18

Consider ketorolac 15–30 mg and LA into surgical wounds Patients may complain of shoulder pain due to diaphragmatic irritation