question

Laparoscopy became more popular with the advent of ______ and means of ___-______ display and ___________. These inventions reduced the complication rate.

answer

television on-screen magnification

question

1901-________ exam of peritoneal cavity, known as ________, attempted by german surgeon ______ ______ to evaluate effects of pneumoperitoneum on intraabdominal hemorrhage. -1910 Jacobaeus used a cystoscope to examine the abdominal cavity 1975-________ first attempted organ resection via _________ (salpingectomy) 1981-________-first lap ______; revolutionary figure, called for suspension of his medical license and journal considered his work to be unethical 1988-_______&_______-first performed lap ________. required development of means of placing _____ _______. >95% of these are now performed laparoscopic

answer

endoscopic "celioscopy" George Kelling Tarasconi laparoscopy Semm appendectomy Reddick and Olsen cholecystectomy surgical clips

question

Laparoscopy-AKA _____ ______ _______ that is performed through multiple small incisions, employing a _______ and a ___________ for visualization

answer

minimally invasive surgery camera pneumoperitoneum

question

Equipment for laparoscopy: _______-cannulas through which cameras and ___________ are inserted into abdomen _________-now all _______, using FO ________ operated instruments are inserted via multiple small ________ (____-____cm)

answer

trocars instruments cameras digital Hand incisions 0.5-1.5 cm

question

Pneumoperitoneum-________ of the abdominal cavity to allow ________ and surgical _______. Initial creation of this is responsible for significant proportion of complications.

answer

insufflation visualization manipulation

question

Pros of laparoscopy: -smaller incisions and decreased ______ _______ -reduced _______ -decreased _________ -_______ length of stay in hospital -decreased risk of _________

answer

stress response bleeding pain shorter infection

question

cons of laparoscopy: -Loss of ____ _____ ______ with hands -_____ ______ is compromised due to ___ camera -limited _______ -steep _____ ________ -multiple physiological changes that can be deleterious to patient __________

answer

direct organ contact depth perception 2D ROM learning curve health

question

2 methods of pneumoperitoneum: -_______ _________ introduced-connected to ____ _____ ______ to allow insufflation. Pierces abdominal wall at ________ point, either _____ or ______ umbilical. -_______ ________-1-____ cm midline _______ incision at lower border of ________. insertion of initial _______ with high flow rate gas connected. (this is much more _______ with newer surgeons)

answer

Veress needle high flow gas thinnest infra or intra Hasson technique 2.5 vertical umbilicus trocar common

question

Insufflate the cavity until ______ ______ is reached. ___-_____ mmHg pressure is most common. Rarely will increase beyond _____mmHg. Machine will automatically stop gas flow when set pressure is reached.

answer

pressure limit 10-15 15

question

magnitude of patient response to pneumoperitoneum depends on: degree of ______, length of _______, patient ________, age, periop ______ ________, and presence of preexisting _______ or _______ disease.

answer

IAP (intra-abdominal pressure) surgery position volume status pulmonary cardiac

question

Complications of pneumoperitoneum occur from the _____ mechanical _______ which causes stimulation of _________ responses

answer

direct pressure neurocirculatory

question

Safest way to establish pneumoperitoneum:

answer

cut down with needle insertion (from review in class)

question

Why is CO2 used for insufflation? -it is ________ -can be _____ by _______ and ______ by _______ system -it is non _______ and much of laparoscopic surgery will employ ________ -risk of _____ ______ is lower than with other choices

answer

physiological absorbed vasculature eliminated respiratory flammable cautery gas embolism

question

Other gases used for pneumoperitoneum: (5)

answer

air N2O argon helium oxygen

question

CV effects: -_______ venous return, decreased _________ -increased _______ and ______-not a reliable measure of cardiac filling pressures during pneumoperitoneum -_____ decreases secondary to decreased venous _______ -CO-usually _______; proportional to increase in ________. ___-____% decrease immediately after _________. CO can increase due to ______ _______

answer

decreased LVEDV RAP PAOP SV return decreased IAP 10-30 insufflation stress response

question

Insufflation pressures >______mmHg collapse ______ and cause drastic ____ in venous return

answer

18 cava decrease

question

Heart rate-______; often ______ to changes in filling or pressures

answer

variable compensatory

question

SVR, PVR, and MAP-_______ due to mechanical and ______ _______. compression of ______ vessels and release of ________ hormones (vasopressin and renin)

answer

increase stress response IA neuroendocrine

question

SVR ______ is attenuated by _________ _________, reverse _________ worsens the increase

answer

increase trendelenburg position trendelenburg

question

_________-caused by increased _____ tone due to stretching of _________ and compression of ________ and most often causes __________

answer

arrhythmias vagal peritoneum vagus bradycardia

question

The drift towards normal _____ values after initial changes seen with _______ are thought to be due to _________ changes.

answer

CV insufflation neurohormonal

question

Elderly patients have less _______ mechanisms

answer

compensatory

question

Increase IAP causes ______ displacement of the diaphragm, causing collapse of ______ portion of lung. this causes decreased ________ and increased ________

answer

cephalad dependent compliance PIP

question

Pulmonary effects: -_____ arterial oxygenation -decreased _______ and ______-->worse in obese and _______ -atelectasis, _______, increased _______ ________ -increased _______ with _____ pH due to high solubility of _______ and smaller ______

answer

decreased FRC TLC COPD shunting airway pressures PaCO2 decreased CO2 TV

question

What position attenuates all of the bad pulmonary effects of insufflation?

answer

reverse trendelenburg

question

What positioning makes all of the bad pulmonary effects worse?

answer

trendelenburg

question

In patient with severe _____ disease )ASA ____ or more, the rise of _______ is unreliable. ________ may not be a reliable index of _______ during __________.

answer

pulmonary 3 PaCO2 ETCO2 PaCO2 insufflation

question

What can occur when the patient is put in steep trendelenburg positioning for surgery?

answer

endobronchial displacement of ETT (if patient desats:turn up O2, listen to BBS)

question

What can you do besides increasing FIO2 to improve oxygenation while patient is in trendelenburg with high peak pressures?

answer

-put on pressure control (40 limit for pressure) -increase TV -increase RR **important to adjust before exsufflation***

question

In patient with pulm disease, __________ is preferred due to decreased postop ventilatory compromise

answer

laparoscopy

question

________ and mechanical stress of pneumoperitoneum cause increased outflow of _________ and ________ release

answer

hypercapnia SNS catecholamine

question

increased ___________ release immediately after insufflation. ______ activity-____x increase in _____ and ________ concentrations Effect is the increase in _______ and _____

answer

vasopressin RAS 4 renin aldosterone SVR PV

question

increased PaCO2 causes increased cerebral ______ ______ velocity. when patient is normocarbic, CBF ________. -increase ________-independent of _________ -_________ pressure increase may occur with steep head-down position (glaucoma)

answer

blood flow normalizes ICP PaCO2 intraocular

question

What does insufflation do to renal and hepatic systems?

answer

-decrease RBF, GFR, UOP -release of ADH and acidosis causes vasoconstriction -changes in hepatic blood flow are controversial (vasodilating effect of CO2 is thought to attenuate increased splanchnic blood flow)

question

What can cause a gas embolism?

answer

-direct needle placement into vessel -gas insufflation of an abdominal organ

question

Incidence of gas embolism

answer

0-69% (highly controversial bc not all cause serious CV effects-microemboli)

question

Treatment of gas embolism-

answer

exsufflate, flood field with saline, if CVL aspirate, listen for "mill-wheel"

question

What can cause vascular injury?

answer

1. trocar or needle into aorta, vena cava, iliac vessels 2. inadvertent disruption of cystic or hepatic artery during lap chole 3. injury to abd wall vessels

question

treatment for vascular injury:

answer

if hemorrhage severe, exsufflation and conversion to an open procedure to control bleeding

question

what 3 types of pneumos can occur?

answer

pneumothorax, pneumomediastium, or pneumopericardium

question

If patient begins to desat during surgery and has tracheal deviation, what is likely the problem and what is the treatment?

answer

tension pneumo -alert surgeon, call for help, and do needle decompression (2nd intercostal space, midclavicular line), chest tube, peep

question

causes of different pneumos that can occur:

answer

1. embryonic defects in pleuroperitoneal hiatus 2. diaphragm defects (gas gets around aortic and esophageal hiatuses) 3. pleural tears 4. bullae rupture

question

treatment for pneumomediastium or pericardium:

answer

-usually resolves in 24 hours -dependent on level of hemodynamic compromise

question

GI injury can be due to: treatment:

answer

trocar or needle insertion into bowel, liver, spleen or mesentery -surgical repair

question

What cardiac arrhythmia is most common? treatment?

answer

bradycardia -exsufflation if severe, or anti-muscarinic (glyco or atropine), or sympathomimetic (epi)

question

What can cause subQ emphysema? treatment?

answer

incidental extraperitoneal insufflation -no treatment unless local compression compromises pt status -will absorb the gas

question

What nerve injuries are a risk with trendelenberg? What about with lithotomy?

answer

-brachial plexus from shoulder braces -common peroneal (fibular) nerve; if prolonged can also cause compartment syndrome

question

Laparoscopy can be safely performed on patients with a wide array of comorbidities. Patients at increased risk of poor outcome include: -increased ______-tumors, hydrocephalus, head trauma -______ (eyes) -________ disease-cystic fibrosis -poor ______ function-CAD, CHF, terminal valve insufficiency

answer

ICP glaucoma respiratory CV

question

What is the recommended airway? Why?

answer

ETT with controlled ventilation bc it decreases CO2 and vent compromise associated with insufflation

question

what airway is acceptable for pelvic laps? IAP kept <_______ can not use in patients iwth other LMA contraindications such as ______ or _________

answer

pelvic laps 15 mmHg obesity GERD

question

NMBA must be appropriate for _______ ________. increased risk of _______ associated with reversal.

answer

surgical length PONV

question

ASA ___+ may require invasive monitors during pneumoperitneum. ETCO2 is always a standard monitor.

answer

3

question

intraoperatively: -increase _____ about ____% to keep patient normocarbic -liberal _____ will decrease CV effects -use of ____ is controversial

answer

MV 15 IVF N2O

question

rule of 15:

answer

when using an LMA: less than 15 degree tilt, <15 mmHg IAP, <15 min duration

question

nitrous can diffuse into ______, causing _______ and increases risk of _________ (all controversial)

answer

bowel distention PONV

question

What can cause sphincter of oddi spasm? what is the treatment?

answer

intraop use of narcotics that interferes with intraop cholangiogram -treat with glucagon, nitroglycerine, or naloxone

question

CO2 is a _______ irritant that may cause abdominal, incisional, or _______ pain that can be treated with opioids, nsaids, and injection of local at site

answer

diaphragmatic shoulder

question

Avoid large doses of ________ to attenuate PONV. Administration of 5HT3 inhibitors closer to ______ is more effective

answer

narcotics extubation

question

Preop with cardiac pt: -________ if EF <_____% -possible monitors: -open _______

answer

echo 30 art line, PA catheter, TEE, ST analysis Lap

question

intraop with cardiac pt: -slow _________ -low ______ -________ augmentation prior to insufflation -drugs: -experienced surgeon

answer

insufflation IAP preload (give fluids if will tolerate) remifentanil, vasodilating drugs like nicardipine, nitroglycerine, inotropes

question

Postop with cardiac patient: -_______ recovery -use of ______

answer

slow clonidine

question

Cholangiography adds ___-____min to lap chole.

answer

30-120

question

Lap appendectomy is always a ___________. If female of childbearing years:

answer

RSI check pregnancy test bc can present with similar symptoms with pregnancy

question

-Lap nissen-always ______, CRNA responsible for insertion of large rubber ________

answer

RSI bougies

question

with a lap __________, prepare for labile swings in BP

answer

adrenalectomy

question

lap bowel resection: if for obstruction do __________, may use ____-______ so maximize relaxation

answer

RSI hand-assist

question

lap inguinal hernia repair-usually in _______; adequate ________ _____ makes procedure easier

answer

males muscle relaxation

question

lap hysterectomy-potential for ____ ____ or _______ compromise

answer

blood loss ureter

question

lap tubal-insure _____ _______ test. usually performed ___-____ weeks post delivery--may still be an ______ risk

answer

negative pregnancy 4-6 aspiration

question

has a highly variable procedure length--be prepared for everything

answer

exploratory laparoscopy

question

west lung zones: 1- 2- 3-

answer

PA>Pa>Pv Pa>PA>pv Pa>Pv>PA

question

supine patients develop _____ ______ due to vascular congestion in the _____ portions (zone __) of the lung and changes compliance. _______ ________ in obese patients

answer

VQ mismatch dorsal 3 aortocaval compression

question

lateral patients: VQ mismatch ______ due to gravitational forces. _______ is greater in down lung and ________ is better in up lung. minimal _____ alterations unless __________

answer

increases perfusion ventilation CV hypovolemic

question

lithotomy-abdominal contents are displaced ______ and decrease _____ and increase _______. causes decreased ________

answer

TV peak pressures CO

question

Robotic surgery: -changes from ____ to _____ -fluid replacement-consider _____ and surgical field -_____ _______ is necessary -positioning usually ______ ______ _______ -lateral position can lead to _______

answer

2D 3D edema muscle paralysis steep head-down rhabdo

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