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62 Cards in this Set
- Front
- Back
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Laparoscopy
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a minimally invasive surgical procedure which allows endoscopic access to the peritoneal cavity after the introduction (insufflation) of gas (CO2) to create space between the anterior abd wall and the viscera; frequently used in place of open procedures, virtually no abdominal organ is exempt
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Benefits of laparoscopy
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- decr trauma
- decr pain - decr cost - decr complications - decr incision size - decr LOS |
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"Endoscopy" was coined in 1867 by Segeles and Dormeaux with the use of...
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a concentrated light source through a speculum
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Initial endoscopy procedures consisted of
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lysis of adhesions
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During the 1960s-1970s, what specialty did laparoscopy become vital to?
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GYN
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The first laparoscopic _____ was done in 1988.
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cholecystectomy
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How are pts selected for laparoscopic technique?
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operative indications same as for open procedures
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What is the only absolute contraindication to laparoscopy?
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contraindication to general anesthesia
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_____ patients prove more difficult to complete laparoscopy without converting to open.
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obese and those with prior abdominal procedures
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Relative contraindications to laparoscopy
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portal HTN, coagulopathy
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Patient and procedure selection should be guided by the experience of ...
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the surgeon and the anesthetist
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List the common procedures performed laparoscopically:
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- cholecystectomy
- thoracoscopy - inguinal hernia - appendectomy - hiatal hernia - nephrectomy - colectomy - diagnostic lap - tubal ligation - uterine sx. -hysteroscopy -hysterectomy -bariatric surgery |
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General contraindications for laparoscopy
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- bowel obstruction
- ileus - peritonitis - intraperitoneal hemorrhage - diaphragmatic hemorrhage - severe cardiorespiratory disease |
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Relative contraindications for laparoscopy
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- morbid obesity
- inflammatory bowel disease - large abdominal mass - advanced pregnancy after 23rd week -Sickle cell -Increased ICP -Patient refusal -inexperienced surgeon |
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2 types of needles that can be used for insufflation
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tuohy, veress
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Insufflation is used to create _______. _____ mode is preferred, using ____ gas at a ____ flow rate.
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pneumoperitoneum, manual mode, CO2 gas, 5 L/min
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The pneumoperitoneum pressure limit is
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about 15mmHg
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Equipment used for laparoscopy
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- light source
- cameras - probes - scalpels - forceps - suturing devices - electrocautery |
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What are the 4 potential causes for major physiologic change during laparoscopy in the anesthetized pt?
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- initial T-burg
- intro of exogenous CO2 - reverse t-burg - creation of pneumoperitoneum to separate abd wall from viscera |
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What are the anesthetic implications of pneumoperitoneum?
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- surgical site accessed using trocars
- pt positioned to displace abd viscera away from surgical site - CO2 used |
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Why is CO2 used for pneumoperitoneum?
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does not support combustion
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What are the possible complications associated with laparoscopy?
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- subcutaneous emphysema
- pneumomediastinum - hemorrhage - cardiovascular compromise - hypercarbia - pneumothorax - gastric perforation - trauma to major organs - gas embolism - pneumopericardium - post op: N/V, pain |
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Describe the unique post op pain associated with laparoscopy
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- biliary colic: dull, aching (not abdominal wall pain)
- neck and shoulder pain - pneumoperitoneum irritates diaphragm causing referred pain - residual CO2 causeing peritoneal irritation and pain (Forms carbonic acid in contact w peritoneum) - CO2 not very soluble in peritoneum- stays longer to cause referred pain |
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What are the modalities of anesthesia that laparoscopy may be performed under?
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general, local, regional
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What is the risk involved in absorption of CO2 during laparoscopy?
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rise in PaCO2 and hypercarbia
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What are the 2 mandatory steps to prevention of hypercarbia during laparoscopy?
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1. controlled hyperventillation: TV 12-15 mL/kg, muscle relaxant to reduce degree of intraabdominal pressure needed for visualization
2. anxiolysis: premedication, undue anxiety can further stimulate the sympathoadrenal response |
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During laparoscopy, the use of N20 is controversial and not recommended due to
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its effects on incr bowel distension and causing PONV
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After induction and prior to trocar placement, it is advisable to place...
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an OGT to avoid gastric distension, and a urinary catheter to prevent bladder distension
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What are the components to general anesthesia for laparoscopy?
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1. anxiolytic prior to induction
2. narcotics/nsaid for pain 3. induction (per hx) 4. muscle relaxant (for intubation, to provide surgical exposure, improved ventilation during pneumoperitoneum) 5. ETCO2 monitoring 6. SCDs (DVT prophylaxis - incr risk due to intraabdominal pressure and incr venous stasis) |
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_____ occurs 42% of the time with laparoscopy and is the #1 reason for hospital admission post op.
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PONV
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What are some techniques for treating the PONV that is associated with laparoscopy?
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1. use of OGT
2. prophylactic meds (zofran 4 mg 30 min prior to end of case; anzemet 12.5 mg preop; reglan 10 mg at start of case; decadron 4-8 mg at start of case) |
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Why does laparoscopy cause PONV so frequently?
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caused by peritoneal distension, bowel distension secondary to CO2 diffusion into the bowel
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How does trendelenberg position affect the patient undergoing laparoscopy?
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- causes upward displacement of abdominal organs for visualization
- upward displacement of diaphragm - further aggravates pulmonary effects of pneumoperitoneum (high intrathoracic pressure, alveolar atelectasis, hypoxemia) |
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How does reverse t-berg position affect the patient undergoing laparoscopy?
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- improves pulmonary dynamics
- decr venous return - decr CO |
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What are the respiratory changes associated with laparoscopy?
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- incr intraabdominal pressure and volume causes cephalad displacement of the diaphragm
- decr in lung compliance 30-50% - incr PIP - decr FRC and incr atelectasis - VQ mismatch - subcutaneous emphysema - pneumothorax (sudden incr in airway pressures and arterial desat) - resulting hypercarbia and hypoxia |
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Hypercarbia during laparoscopy enhances ________ and CO2 is absorbed from the abdomen into the _____.
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VQ mismatch, blood
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Gas embolization during laparoscopy manifests as...
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decr BP, cyanosis, hypoxia, tachycardia, dysrhythmias
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What are the dysrhythmias seen with laparoscopy and why?
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dysrhythmias (Bradycardia and/or asystole) due to peritoneal stretching and reflex incr in vagal tone (REFLEX BRADY) -- highest risk group females having GYN/OB procedures
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How are dysrhythmias during laparoscopy treated?
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reduction in pressure (release pneumoperitoneum)
admin anticholinergic to incr HR (atropine, robinul) |
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What cardiovascular effects are seen as a result of the incr intraabdominal pressure during laparoscopy?
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- compresses both venous capacitance and arterial resistance vessels
- cardiac output decr by 30% (preload) - incr MAP and SVR (afterload) - pooling of blood in legs - caval compression/ decr venous return - stimulation of peritoneal receptors (release neurohumoral factors - vasopressin, catechols) - incr vascular resistance of intraabdominal organs |
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Describe hysteroscopy procedure and positioning
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- large amt of fluids used as distending medium to visualize endometrium
- may cause fluid overload and hyponatremia - LMA acceptable bc no pneumoperitoneum (except diagnostic procedures) - t-burg w lithotomy |
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How is post op pain managed after hysteroscopy?
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NSAIDs
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VATS
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video-assisted thoracic surgery
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What are the anesthesia considerations for VATS?
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- double lumen ETT w OLV
- lateral decub position - lung deflation causes VQ mismatch - may need a-line |
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What time during laparoscopy is the patient most vulnerable to hemodynamic instability?
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during initial insufflation -- – if HR drops during insufflation, have surgeon deflate, then when improved HR, slowly reinflate to be safe
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Trocar:
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tube that goes through holes in abdomen to maintain pressure of CO2 -- other holes hold instruments w calipers/grabbers
trocar hole usually just below umbilicus |
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Sudden increases in airway pressure and arterial desaturation are indicative of what?
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pneumothroax
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What is general anesthesia?
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-a drug that brings about reversible loss of consciousness
*theses drugs are generally administered by an anesthesia provider in order to induce or maintain general anesthesia to facilitate surgery |
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Anesthetics are divided into what two classes?
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1. Inhalation Anesthetics (gases/vapors, usually halogenated)
2. Intravenous Anesthetics (injections, anesthetics or induction agents) |
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What are the 4 components of GA?
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-Analgesia=perception of pain eliminated
-Hypnosis=unconsciousness -Depression of spinal motor reflexes -Muscle relaxation |
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What does the preop phase require?
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1. comprehensive preoperative assessment that includes an H&P with emphasis on airway and allergies
2. last oral intake of food/liquid and meds 3.prior anesthetic history/reactions/MH 4. All appropriate labs/tests/ECG and other diagnostic info available |
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The ____ should be consistent with the amount of info required to ensure cardiopulmonary stability throughout the surgery or procedure.
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monitoring
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What monitoring is required throughout the use of GA?
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-BP
-HR -SpO2 -ETCO2 -O2 -Inhalation agent if used -Ventilation -Temp if necessary |
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The type of anesthetic induction will be determined by the ____ and ___ status of the patients, ____ status, ____ of the procedure and whether ____ of the trachea is required.
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-age and physical status, NPO, urgency of the procedure, intubation of the trachea
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You must constantly assess the ____ ____ to ensure adequate ventilation and oxygenation. If there is a problem you must deal with them to the point of securing the ____.
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airway patency
airway |
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The choice of _____ depends of your assessment of the ______ and _____ status of the patient. One must consider factors that may contraindicate the use of certain drugs or techniques.
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anesthetic
cardio and pulmonary status |
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Do no use _____ with egg allergy
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propofol
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______ should not be used in patients post burn, with paralysis, hyperkalemia, and a history of MH
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succinylcholine
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Performance of a _____ technique is contraindicated in a patient who refuses or has a coagulopathy or septic process.
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regional
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Do all patients require the reversal of muscle relaxants?
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-not necessarily
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make sure you meet _____ criteria before extubating.
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extubating
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what are the 5 components of the postop period?
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1. the course is related to the operative procedure and the techniques and agents utilized
2. the incidence of airway reactivity is higher in patients who were intubated 3. monitoring of HR, BP, temp, SpO2, airway status and respiration is essential 4. N&V, pain, respiratory depression, delirium, and hypothermia are all relatively common complications seen following GA 5. the individual anesthetist can have significant impact on the severity of most complications that might occur in the post op period. |
