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FLS Flashcards

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1
Q

Benefits of Laparoscopy

A
  1. Faster recovery
  2. Cosmesis
  3. Less post operative pain
  4. Reduced adhesion
  5. Equivocal surgical results
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2
Q

Benefits of laparotomy

A
  1. Direct palpation of tissue
  2. Intuitive motion
  3. Easy abdominal access with unrestricted movement
  4. 3D
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3
Q

Surgeries that can use local anesthetic +/- mild sedation

A
  1. Diagnostic laparoscopy
  2. Bilateral tubal ligation
  3. Select inguinal hernia repair
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4
Q

Laparoscopic surgery physiology: CV

A
  1. Dec Cardiac output (Dec flow in IVC -> Dec preload)
  2. Dec splanchnic blood flow
  3. Dec cardiac output -> Increases afterload
  4. HR: Sinus tachycardia, PVC
  5. Inc lower extremity stasis and higher risk of VTE

Mechanism: Pressure/mechanical
Chemical = Hypercarbia
Trendelenburg

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5
Q

Laparoscopic surgery physiology: Pulmonary

A

Inc minute ventilation (Min Vent = TV x RR) to expel CO2
Inc peak airway pressure
Dec Functional residual capacity
Dec pulmonary compliance
Dec residual volume
Reduced diaphragmatic excursion - Upward displacement and stiffening of diaphragm
Decreased FRS and Reserve Volume for oxygenation = Atelectasis/VQ mismatch

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6
Q

CO2 accumulation

A

Greatest in first 15-20 minutes
Requires monitoring with end tidal CO2
Then reaches steady state

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7
Q

Hypotensive patient during laparoscopy

A

Desufflate
Check insufflator setting
Confirm adequate relaxation
Check intravascular volume status
Look for bleeding

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8
Q

Laparoscopy physiology: Renal

A

Oliguria - Renal compression
UOP is unreliable indicator of volume status
Intraoperative bolus can lead to cardiac failure, pulmonary edema
Chemical: Renin & ADH release - Reabsorption of Na, H2O, K excretion
Intraoperative oliguria self limiting after a few hours

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9
Q

Hypercarbia

A

CO2 from pneumoperitoneum absorbed in circulation

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10
Q

Hypercarbia effect on BP

A

Increase
Hypercarbia -> Sympathetic stimulation -> Increased SVR & Pulmonary vascular resistance -> Increased BP

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11
Q

Hypercarbia effect on pH

A

Acidemia
If CO2 not cleared by compensatory ventilation

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12
Q

Hypercarbia effect on cardiac output

A

Decreased
Hypercarbia -> Acidemia -> Decrease myocardial contractility -> Decreased Cardiac output

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13
Q

Hypercarbia effect on HR

A

Tachycardia, arrhythmia

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14
Q

Venous flow during pneumoperitoneum

A

Venous flow decreased 20-40%

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15
Q

Vagal stimulation

A

Stretching of peritoneum, pelvic organ manipulation, cervical stretching with manipulation = Bradycardia

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16
Q

Pneumoperitoneum (CO2)

A

Use warm CO2 - Improves patient temperature and post operative pain
Gas embolus 0.015%
Clinically insignificant gas more common

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17
Q

Hypotension, Tachycardia, JVD, mill-wheel mumur

A

CO2 embolus

Treatment:
1. Desufflate
2. Place in left lateral Trendelenburg (prevents embolus from entering right ventricular outflow tract)
3. Aspirate from central line

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18
Q

Contraindications to laparoscopy (Absolute)

A

Inability to tolerate laparoscopy
Hypovolemic shock
Lack of proper surgeon training
Lack of institutional support

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19
Q

Contraindications to laparoscopy (Relative)

A

Inability to tolerate general anesthesia
Long standing peritonitis
Large abdominal or pelvic mass
Massive incarcerated ventral or inguinal hernia
Severe cardiopulmonary disease
Acute glaucoma, retinal detachment, Inc ICP, VP shunt

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20
Q

Obesity and Laparoscopy

A
  1. Dec lung compliance
  2. Dec abdominal wall compliance = Higher insufflation pressure
  3. Heavy omentum putting pressure on diaphragm
  4. Thick subcutaneous tissue causes tunneling and prevents motion
  5. Higher conversion laparotomy, longer operating times, longer hospitalization
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21
Q

Laparoscopy in thin patients

A

Elevate abdominal wall
Open/Hassan, Optic trocar
Place Veress away from midline near costic margin

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22
Q

Ergonomic position

A

10-20 degrees below eye level

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23
Q

Patient position: Supine

A

Do not abduct arms >90 degrees: Prevent brachial plexus injury
Hands to void table break

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24
Q

Patient positioning: Tucked arms

A

Pelvic surgery

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25
Patient positioning: Arms out
Upper abdominal surgery
26
Set up: Reverse trendelenburg
Foot board to prevent sliding Belt across thighs to prevent knee buckling
27
Lithotomy
Allen stirrups > Candy canes (Femoral nerve hyperflexion) Knees should be at level with abdomen to allow surgeon movement (upper abdominal/colon surgery)
28
Lateral decubitus surgery
Renal, Adrenal Roll in axilla on dependent side - Prevent brachial plexus injury Bean bag to hold patient up - Can cause pressure injury Break bed to increase space between costal margin and iliac crest
29
Modified lateral decubitus
Splenectomy, Nephrectomy, Adrenalectomy Allows rotation of operating table between lateral decubitus and supine Allow for removal of large specimens Easy conversion to laparotomy Avoids flank incisions - Not tolerated well
30
Abdominal entry
1. Blind trocar 2. Open/ Hasson 3. Opti view 4. Varess
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Blind trocar insertion contraindication (Relative)
1. Previous abdominal surgery 2. Previous intraabdominal inflammatory process
32
Blind trocar insertion contraindication (Absolute)
1. Abdominal scar from prior open surgery in vicinity 2. Placement of trocar through mesh
33
Diagnostic Laparoscopy
Reason: Uncertain etiology 3 port along the left abdomen (First - LUQ)
34
Laparoscopic Liver Surgery
Angled/ Flexible scope, may need ultrasound
35
Anterior abdominal wall surgery
30 degree scope
36
Appendicitis
Tuck both arms Trendelenburg + Left tilt
37
Running small bowel
3 ports on left side of abdomen Screen: Right shoulder & hip Normal bowel: Ligament of Treitz -> Ileal cecal valve SBO: Ileal cacal valve (decompressed) -> Ligament of Treitz
38
Trauma
Angled scope Tuck both arms
39
Pelvic Surgery
Tucked arms 0 Degree scope
40
Mediastinum
Arms out 0 Degree scope
41
Set up: Retroperitoneal
Ports along costal margin (Access to kidney and adrenals) Above Iliac bifurcation - Modified lateral decubitus Mobilization of colon Below Iliac bifurcation - Supine w/ Trendelenburg
42
Use electrocautery for biopsies?
No - makes patholgoy suboptimal
43
Large lesions
Incisional biopsy
44
Small lesions
Excisional biopsy
45
FNA
20-22 gauge needle
46
Core needle biopsy
14-18 gauge needle
47
Biopsy forcep
Small peritoneal implants (incisional or excisional)
48
Wedge biopsy
Scaple, Scissors, stapler (Incisional or excisional)
49
Liver biopsy
Most common: Core needle, Wedge resection DO NOT biopsy vascular lesions Cysts do not require biopsy
50
Ovary biopsy
Oopherectomy vs Wedge biopsy vs Forcep biopsy Type of biopsy determined by menopausal status, concern for malignancy
51
Bowel biopsy
Excise small lesions - Close serosa with stitch
52
Laparoscopic suturing
Tapered needle > Cutting Ports: 10 cm apart Tension provided with continuous stitches (requires assistant) or locking
53
Sliding square knot
Useful for tissue under tension Controls suture tightening
54
Intracorporeal knot tying
15 cm suture
55
Extracorporeal knot tying
Suture 75 cm + Knot pusher
56
Roeder’s Knot (Endoloop)
End of blood vessel Appendix Fallopian tube Cystic duct
57
Port sizes: Needles
8 mm port
58
Port sizes: Clips
8 mm , 10 mm Good for tubular structure. Not good for bowel Reusable - Requires reloading with each clip Disposable - Can place multiple clips without reloading
59
Port sizes: Staples
12 mm port Length: 30-60 mm Places 2-3 rows of staples on each side
60
Staple sizes: White
Vascular: 2-2.5 mm
61
Staple sizes: Blue
GI tract: 3-3.5 mm
62
Staple sizes: Green
Distal stomach, Inflamed GI tract: 4-4.5 mm
63
Port site bleeding
Suture (Keith, suture passer, spinal needle) Clip Foley catheter (Temporary)
64
Peritoneal washing
100 mL NaCl Wait 3-5 minutes before suction
65
Port site closure
Hernia risk <5% Open Laparoscopic assisted Sole laparoscopic
66
Common causes of unrecognized bleeding
1. Trocar injury 2. Vessels/organs away from operative field (Liver, spleen) 3. Venous bleeding tamponaded by pneumoneritoneum
67
Post operative resolution of pneumoperitoneum
Peak decrease within 30 minutes Resolution within 3 hours
68
Post operative care: Nausea & Vomiting
Risk of aspiration Wound breakdown Failure of intraoperative hemostasis, tissue pedicle control
69
Post operative care: Pain
Referred pain to the shoulder - Conversion of CO2 to carbonic acid irritating diaphragm (1-3 days post op) Prevention: Local anesthetic, lower insufflation pressure, evacuation of pneumoperitoneum, multimodal analgesia
70
Presentation of hollow viscus injury
Presents 1-7 days post surgery
71
Solid organ injury
Bleeding not appreciated during operation Pancreas injured in splenectomy, left adrenalectomy, colon surgery — Pancreatic ascites, pseudocyst development
72
Bowel injury
0.0006 - 0.0016% (1 per 1000)
73
Vascular injury
0.00009 - 0.005% (5 per 1000)
74
Types of injuries during laparoscopic surgery
1. Hollow viscus injury 2. Solid organ injury 3. Bowel 4. Vascular 5. Nerve 6. Thermal burn 7. Hernia 8. Port site metastasis
75
Port site metastasis
1%
76
Types of gas supply
CO2, NO, Helium, Air, Argon
77
Nitrous oxide
Advantage: Less acid/base disturbance Less post operative pain Inc tolerance of pneumoperitoneum without general anesthesia Cannot be used in cases with bowel perforation - Inc fire risk
78
Argon, Helium (Inert gas)
Advantage: Less acid/base disturbance Disadvantage: Expensive Inc extaperitoneal gas extavasation (Gas embolus) Dec avalability
79
CO2 - Gas supply
Advantage: Dec combustion High diffusion coefficient (20x O2) -> Soluble in blood -> Eliminated in alveoli
80
Dark or blurry image
Check fiberoptics - Hold lens up to light. Small black areas may present if damaged Inspect lens Moisture on eye piece
81
Defogging laparoscope
Wipe lens with defogging agent Heated bath or scope warming device
82
Light source
300 W Xenon light source Fire risk to sterile drapes
83
No CO2 (gas supply)
Confirm tank is full - May read empty if connected to central CO2 supply Spare CO2 gasket available Confirm for air leaks
84
No image
Ascertain monitor is plugged in
85
Impeded laparoscopic view/loss of working space
Check insufflator control panel
86
If measured pressure is < or = to preset pressure but flow is absent
Insufflator problem 1. Wrong pressure for pneumoperitoneum 2. Inadequate muscle relaxation 3. Incorrect valve connection for insufflator 4. Tubing obstruction
87
Low pressure, High flow
Check insufflator tubing is connected Check all port valves are closed Check for leaking CO2 from port sites Check for distention of bowel or foley bag (Bowel/bladder injury)
88
Low pressure, absent flow
Power off CO2 running low
89
Blank video screen
Disconnected power cord Disconnected video cable Disconnected light cable (scope or light source) Blown light source bulb
90
Monopolar
Low -> High frequency Required dispersive electrode (Bovie pad) High resistance Lateral spread High energy requirement Needs dry operative field
91
Cut
Low voltage Tissue desiccation due to temperature rise -> Water evaporation = Desiccation Inc Desiccation -> Inc tissue impedance until complete -> Current stops flowing due to high resistant -> Tissue turn brown, steam, bubbles - Minimal lateral tissue damage - Limited thermal coagulation - Does not need direct contact
92
Coagulation
High voltage, intermittent wave form Tissue coagulation due to tissue heating (>60C) -> Protein denaturing -> Cool 0> Reform in new pattern -> Tissue coagulation Rapid surface heating, shallow depth of necrosis (fulguration) Noncontact - Relies on sparking between device and tissue
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Blend
Adds hemostatic effect to cutting
94
Current Diversion
Current passes through unintentional tissue due to path of least resistance Fix: Insulate scope Use low voltage and power Activate when close to target Use bipolar Do not use hybrid ports (plastic/metal)
95
Capacitive coupling
Transfer of current from active electrode (scope, port) —> Insulator —> Passive electrode (capacitor) Needs 2 conductors to be separated by insulator Metal object holds charge until it can release on another object causing inadvertent injury Example: Metal port with plastic screw Fix: Using plastic ports or all metal trocars
96
Direct coupling
Transfer of current from active electrode to metal
97
Narrow return circuit
Current passes through ligated tissue in logarithmic fashion -> Excessive tissue heating -> Delayed perforation If the largest part of tissue is touches, the most narrow region with be affected
98
Bipolar
Low resistance circuit Tissue placed between both electrodes Does not need dispersive electrode (bovie pad) Less lateral spread Lower energy requirement Works in wet environment
99
Disadvantage of Bipolar
Inadvertent thermal injury to adjacent organs Inadvertent cutting of patent vessels before adequate sealing Device will not work if metal within jaws (staples, clips)
100
Disadvantage of Monopolar
Direct coupling Capacitive coupling Narrow return circuit
101
Port placement if prior surgery, umbilical hernia, mesh
Palmar point
102
Laparoscopy in pregnancy
2nd trimester
103
Bleeding staple line after use on omentum
Staples too large
104
Repairing enterotomy
Leave long tails for stay sutures Absorbable sutures
105
Serosal bleeding
Oversew
106
Ultrasonic energy (Harmonic)
Mechanical energy - Electric energy -> High frequency vibration (50,000 Hz) - Passive blade (hold tissue) and active blade (transfers heat) - Higher power = more cutting - Lower power = more coagulation
FES & FLS
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