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51 Cards in this Set
- Front
- Back
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 |
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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 - tibal ligation - uterine sx. |
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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 |
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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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19 mmHg
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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 -- 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
admin anticholinergic to incr HR |
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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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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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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 |