Module 11

Question 1

44 Anesthesia for Laparoscopic and Robotic Surgeries

KEY POINTS

1. Small incisions, decreased postoperative pain, and lower surgical complication rates are some of the benefits of laparoscopy over _______(1).
2. _______(2) and position-related physiologic changes are a significant disadvantage, to the anesthesiologist.
3. Risk of perioperative complications may be significant in patients with body mass index > _______(3) and obesity-related comorbidities.
4. Advances in _______(4) have expanded its application to multiple subspecialties.
5. Access to the patient during robotic-assisted surgery may be seriously limited during an intraoperative _______(5) or airway emergency.
6. Severe _______(6) and acidosis from absorbed carbon dioxide can lead to reduced inotropy, dysrhythmias, and arterial vasodilation.
7. High intra-abdominal pressures during _______(7) can severely impair venous return and cardiac filling.
8. Endobronchial intubation can occur during diaphragmatic displacement into the thorax and _______(8) positioning.
9. Renal blood flow, glomerular filtration, and urine output are _______(9) during pneumoperitoneum.

Answer 1

1. laparotomy
2. Pneumoperitoneum
3. 40 kg/m²
4. robotic-assisted laparoscopic surgery
5. cardiopulmonary
6. hypercarbia
7. hypovolemia
8. Trendelenburg
9. reduced

Question 2

Key Points cont.

10. The assessment of neuromuscular blockade during laparoscopic surgery remains highly _______(1).
11. Major vascular injuries occur rarely during _______(2) and are associated with significant morbidity and mortality.
12. Severe hypotension during pneumoperitoneum should be treated with _______(3), and possible conversion to an open procedure.
13. Risk factors for complications of subcutaneous emphysema include operative times more than _______(4), lower BMI, high intra-abdominal pressure, and _______(5) surgery.
14. Tension capnothorax is a life-threatening condition that requires a high index of suspicion and immediate action from the operating room _______(6).
15. Perioperative use of preemptive multimodal strategies and postoperative nausea and vomiting prophylaxis are integral components for optimal patient recovery after _______(7) surgery.

Answer 2

1. subjective
2. abdominal entry
3. desufflation
4. 200 minutes
5. Nissen fundoplication
6. team
7. laparoscopic

Question 3

Definitions

Laparoscopic surgery:
- Minimally invasive surgical technique where specialized tubes are inserted for surgical _______(1)
- Small skin incisions are made, approximately 1 cm in length, to facilitate insertion of rigid tubes, called _______(2).

Laparotomy:
- surgical incision to Open the abdominal _______(3)
- Performed to examine the abdominal _______(4)

Introduction
- Improved surgical _______(5)
- reduced postoperative _______(6)
- faster return to _______(7)
- lower surgical-related complications continue to make laparoscopy

Fast Track Programs:
- facilitated the expansion of laparoscopy into _______(8) facilities
- maximize the benefits of minimally invasive surgery has improved surgical _______(9)
- large number of surgeries that once required prolonged hospital stays are now performed in outpatient surgery centers and _______(10) facilities

Answer 3

1. access
2. trocars
3. cavity
4. organs
5. cosmesis
6. pain
7. work
8. noninpatient
9. outcomes
10. short-stay

Question 4

Venous Gas Embolism (VGE) During Laparoscopic Surgery @ 1:07:57

• Definition and Clinical Significance
  o VGE occurs when CO2 gas bubbles enter the venous system and travel to the right heart, causing obstruction of venous return and potentially right ventricular _______(1).
  o Although a severe complication, symptomatic VGE is infrequent in laparoscopic _______(2).
• Prevalence Observed with Monitoring
  o Intraoperative TEE monitoring shows subclinical VGE in a significant percentage of laparoscopic surgeries, with a reported range from 20% in radical prostatectomies to almost _______(3) in total hysterectomies.
• Causes of VGE
  o Direct cause: Misplacement of the _______(4) needle into a vein or organ can introduce CO2 directly into the venous system.
  o Indirect cause: During laparoscopic surgery, dissection may open vessels, allowing CO2 to enter the venous circulation.

High-Risk Surgical Actions
- Specific surgical actions such as transecting the _______(1) ligament or dissecting the _______(2) ligament during a laparoscopic hysterectomy have been associated with VGE events.

Influence of Patient Positioning
- The position of the patient during surgery can affect the likelihood and severity of CO2 entrainment into the venous system and the right heart chambers.

EXAM QUESTION: Detection and Management of Venous CO2 Gas Embolism
- Detection
o Clinical signs include:
- Acute _______(3) hr?
- Cardiac _______(4)
- QRS complex? _______(5)
- _______(6) bp?
- _______(7) o2?
- Decreased end-tidal CO2
o Physical exam may reveal:
- _______(8) color?
- “Mill wheel” _______(9) on auscultation
o Most sensitive detection method? _______(10)

Management
- Immediate Actions:
- ____A pneumoperitoneum and decompress abdomen
- Initiate advanced cardiac life support if cardiac arrest occurs
- Administer rapid IV fluids for hypotension
- Employ hyperventilation and 100% O2 to accelerate CO2 removal
- Positioning:
- Place patient in _______(1) and left lateral _______(2) positions to reduce right ventricular air lock severity

Answer 4

Answers: VGE
1. failure
2. procedures
3. 100%
4. Veress

Answers: detection
1. round
2. broad
3. tachycardia
4. arrhythmias
5. widening
6. Hypotension
7. Hypoxemia
8. Cyanosis
9. murmur
10. Transesophageal echocardiography (TEE)

Answers: mngmt
A. Terminate
1. Trendelenburg
2. decubitus

Question 5

Airway Edema: @ 1:09:38

• Causes:
  o Prolonged steep Trendelenburg position
  o Large volume fluid resuscitation
  o Occurs during procedures like robotic _______(1)
• Risks:
  o Induces facial and pharyngo-laryngeal edema
  o Can lead to postoperative airway _______(2)
• Prevention during Recovery:
  o Positioning patient in____A. sitting to facilitate edema reversal
• Assessment before Extubation:
  o ____B test may be considered
  o Limited definition of its efficacy in ruling out significant laryngeal edema intraoperatively
• Management Strategy:
  o If severe airway edema is a concern, plan for:
  
  • Continued intubation
  • Postoperative ventilatory _______(3)

Venous Thrombosis:

• Activation of Coagulation Cascade:
  o CO2 pneumoperitoneum potentially activates the _______(1).
• Venous Outflow Obstruction:
  o Occurs during CO2 _______(2).
• Prevalence:
  o Although low, deep venous thrombosis (DVT) and pulmonary embolism (PE) risks are considered _______(3) with laparoscopic surgery.

Postoperative Management - Laparoscropy

Postoperative Nausea and Vomiting (PONV):
- Increased Risk with Laparoscopy:
o Laparoscopic patients have a higher PONV risk compared to _______(1) procedures.
- Procedure-Specific Risks:
o _______(2) stands out as the highest independent predictor for PONV.
o The nature of laparoscopic surgery follows as a significant predictor.

Answer 5

Answers: AE
1. prostatectomy
2. compromise
3. support
A. Recumbernt
B. Cuff leak
Answers: VT
1. coagulation cascade
2. pneumoperitoneum
3. increased
Answers: postop
1. nonlaparoscopic
2. Cholecystectomy

Question 6

Worst Result of Pneumoperitoneum: CV Arrest
- A significant source of intraoperative and postoperative issues during laparoscopy stems from the creation of _______(1)
- Patient may be _______(2)
o NPO
o Bowel Prep
- May already have cardiac _______(3)
- May not tolerate position _______(4)
o Steep Reverse Trend

Answer 6

Answers:
1. pneumoperitoneum
2. Dehydrated
3. compromise
4. Change

Question 7

Capnothorax @ 1:06:25

• Pathophysiology:
  o Definition: _______(1) refers to CO2 gas accumulation in the pleural space.
  o Mechanism:
  
  • CO2 during insufflation may dissect from the peritoneum into the mediastinum and along the pleura.
  • Uncontrolled thoracic cavity pressurization can cause _______(2), increasing intrathoracic pressure and causing mediastinal shift and venous return decline, leading to right ventricular _______(3). –> life-threatening
• Anatomic Considerations:
  o Connection Points:
  
  • Diaphragmatic defects like the _____A hiatus, _______(4) hiatus, and _____B opening allow abdominal-thoracic connectivity.
• Risk Factors:
  o Similar to Subcutaneous Emphysema:
  
  • Procedures near the _______(5) elevate the risk of capnothorax.
    o Procedural Risks:
  • Higher during diaphragm-adjacent surgeries (e.g.,___C).
  • Potential mechanical injury to the diaphragm (e.g., trocar entry).
  • Rarely, congenital pleurodiaphragmatic channels.

Early Clinical Signs:
- _______(1): lungs?
- Palpable in the upper torso.
- Respiratory Changes:
- Severe hypercarbia, altered ECG axis, and amplitude.
- Physical Examination:
- Diminished breath sounds and chest excursion, either bilaterally or unilaterally.

Acute Presentation of Tension Capnothorax: (3 Hells)
- High _______(2), ______A, severe _______(3).
- Life-threatening, challenging intraoperative diagnosis.

Diagnostic Approaches:
- Intraoperative Suspicion:
- Requires high suspicion and prompt communication with the surgical team.
- Postoperative Imaging:
- Useful for confirmation; _______(4) for assessing lung pathology, including pneumothorax.

Management Strategies:
- Immediate Actions:
- Primary treatment is immediate _______(1).
- CO2 Reabsorption:
- _______A to expedite CO2 removal.
- ______B to mitigate the abdomen-thorax pressure gradient.

Observation and Supportive Therapy:
- Observation:
- Adequate for patients with minimal physiologic impact.
- Cardiac Concerns:
- Patients with preexisting cardiac dysfunction may require additional support.

Emergency Interventions:
- Needle decompression or chest tube placement for severe cases.
- Consideration for laparoscopy termination and** conversion to open surgery** if instability persists.

Answer 7

Answers: patho
1. Capnothorax
2. tension capnothorax
3. compression
A. aortic
4. esophageal
B. Caval
5. diaphragm
C. Nissen fundoplication

Answers: signs
1. Subcutaneous Emphysema
2. peak airway pressures
A. Hypoxia
3. hypotension
4. transthoracic echocardiography

Answers: mngmt
A. Hyperventilation
B. Positive End-Expiratory Pressure (PEEP)
1. peritoneal desufflation

Question 8

Patient’s age and comorbidities can greatly affect the severity of pneumoperitoneum related changes observed by clinicians

In robotic surgery, _______(1) operative time and limited _______(2) to the patient, due to prominent robotic equipment, can further complicate management of urgent conditions.

Answer 8

1. long
2. access

Question 9

Table 44-2 Disadvantages of Laparoscopy Surgery

Patient-specific
- Risk of _______(1)
- Referred pain from _______(2)
- _______(3) Issues (Especially Trendelenburg Hysterectomy)
- _______(4) Emphysema

Surgeon-specific
- Highly-specialized _______(5)
- _______(6) issues
- Limited _______(7) sense
- Longer _______(8) times
- Complex _______(9) and setup
- Use in _______(10) or scar tissue more challenging

Anesthesiologist-specific
- Pneumoperitoneum-induced _______(11) response
- _______(12)
- Mechanical _______(13) challenges
- Extraperitoneal CO₂-related _______(14)
- Limited access to patient (_______(15) surgery)

Answer 9

Answers:
1. PONV (Postoperative Nausea and Vomiting)
2. CO₂
3. Ventilation
4. Subcutaneous
5. training
6. Ergonomics
7. tactile
8. operating
9. equipment
10. reoperation
11. stress
12. Positioning
13. ventilatory
14. complications
15. robotic

Question 10

Table 44-1 Benefits of Laparoscopic Surgery

Patient-specific
- Improved cosmetic _______(1)
- Shorter recovery _______(2)
- Earlier return to _______(3)
- Faster return to normal _______(4)
- Lower _______(5)

Surgeon-specific
- Lower medical _______(6)
- Better clinical _______(7)
- Earlier return of bowel _______(8)
- Lower postoperative _______(9)

Anesthesiologist-specific
- Decreased Incisional Stress _______(10)
- Little/No Opioid _______(11)
- Decreased Post-Op _______(12)
- Minimal Fluid _______(13)
- Minimal decline in Post-op respiratory _______(14)
o They don’t have that pain that prevents coughing, deep breathing, etc.

Answer 10

Answers:
1. results
2. time
3. work
4. activities
5. costs
6. risk
7. outcomes
8. function
9. complications
10. Response
11. Requirement
12. Pain
13. Shift
14. Function

Question 11

Insufflation

• CO2 has a desirable safety _______(1)
• CO2 is highly soluble in _______(2)
  o Rapid pulmonary _______(3)
  o Minimizes the consequences of inadvertent extraperitoneal or intravascular _______(4)
• CO2:
  o Nonflammable
  o Non-oxidizing
  o safe to use during _______(5).

Answer 11

Answers:
1. profile
2. blood
3. removal
4. insufflation
5. electrocautery

Question 12

Intraperitoneal insufflation (cont.)

• established by creating a small subumbilical _______(1)
• Insert Veress _______(2)
• Tubing connected to the Veress stopcock to deliver low-flow rates of _______(3)
  o until adequate abdominal distention is achieved
• Maximal preset intra-abdominal pressures (IAP) above _______(4) mmHg should be avoided
  o Anything Higher than THAT:
  - CO2-related _______(5)
  - significant _______(6) instability
  * If this Happens: _______(7) before trying to treat with Drugs

Answer 12

Answers:
1. incision
2. needle
3. CO2
4. 15
5. complications
6. cardiopulmonaru
7. Stop insufflation

Question 13

Patient positioning during laparoscopic surgery (She goes back to this smh)

• Steep _______(16) (i.e., “head up”)
  o exposes upper abdominal structures, such as in gastric bypass surgery
  o Head up position → increased _______(1), decreased _______(2). and _______(3), blood pooling _______(4)
• Steep _______(17) position (i.e., “head down”)
  o Expose lower abdominal structures, such as in uterine or _______(5) surgery
  o Head down position → increased _______(6) return, and _______(7) filling
• The lateral jackknife position
  o used to expose the retroperitoneal space during radical _______(8) surgery.
• Leftward tilting
  o exposes the _______(9)
• Rightward tilting
  o exposes the left _______(10)
• Lithotomy
  o dependent on the need for genital, urologic access.

Concerns
- _______(11) Injury
- Falling off the _______(12)
- _______(13) Issues
- Cardiac Output
o _______(14) changes, Afterload increases
- Fluid _______(15)

Answer 13

Answers:
1. SVR (Systemic Vascular Resistance)
2. CO (Cardiac Output)
3. CI (Cardiac Index)
4. extremity
5. prostate
6. venous
7. cardiac
8. nephrectomy
9. appendix
10. colon
11. Nerve
12. Bed
13. Ventilation
14. SVR
15. Shifts
16. reverse Trendelenburg
17. Trendelenburg

Question 14

Ambulatory Laparoscopic Gastric Bypass surgery

• Unplanned Admission rates were _______(1)
• Unplanned Readmission rate _______(2)
• Henry Ford (Bariatric Center of Excellence)= <_______(3)
• Almost always due to _______(4)
  o Metabolism Issues
• Appropriate patient presurgical screening is ideal for:
  o optimizing good surgical results
  o avoiding unexpected complications
• Patients with a BMI of less than _______(5) and well-optimized comorbid conditions, such as type II diabetes, heart disease, and obstructive sleep apnea, may have acceptable risk for ambulatory surgery
  o Inspire: Hard and Fast at 35, 30 for anything Big
• Concerns for greater risk of perioperative complications exist for patients with BMI greater than _______(6) and poorly managed obesity-related _______(7).

Answer 14

Answers:
1. 16%
2. 1.82%
3. 5%
4. Dehydration
5. 40 kg/m2
6. 40 kg/m2
7. comorbidities

Question 15

Robotic Laparoscopic Surgery

• First popularized in urology for radical prostatectomies, robotic-assisted surgery
• Has since gained ground in other fields, in part, due to reports of improved surgical outcomes
  o Open Prostatectomy: Used to cause high _______(1),
  ■ Now done robotically

STORY TIME: 2…-23:45

[Redacted]

Table 44-3 Examples of Robotic-assisted Laparoscopic Surgery

Cardiac
- Coronary artery _______(2), valvuloplasty

Thoracic
- Lung _______(3), esophagectomy

Gastrointestinal
- Fundoplication, colectomy, gastrectomy, _______(4)

Urologic
- Radical cystectomy, pyeloplasty, _______(5)

Gynecologic, Oncologic
- Hysterectomy, lymph node dissection, _______(6)

Answer 15

Answers:
1. blood loss
2. bypass
3. resection
4. hepatectomy
5. prostatectomy
6. oophorectomy

Question 16

Robotic Surgery

• Remote handling of instruments via a specialized control allows for
  o movements that mimic _______(1) maneuvers
  o improved degrees of _______(2)
  o optimal surgical instrument _______(3) and pivoting.

Answer 16

Answers:
1. natural
2. freedom
3. rotation

Question 17

Anesthetic management

• During laparoscopic robotic surgery requires preparing for patient accessibility limitations and adjusting for patient positioning challenges.
• Prominent surgical robotic equipment near the patient can greatly limit anesthesia provider _______(1) to the patient in case of an emergency
• In the rare event of an airway or cardiopulmonary emergency
  o The robotic surgical arms must first be carefully disengaged from the _______(2), before the robot can be removed safely and the patient positioned in a manner consistent with that needed for airway management or _______(3), respectively.
  ■ PATIENT DYING AND IN A ROBOT CASE.. WHAT DO YOU DO? → ANSWER: _______(6) that DAMN robot (a question may be based on this)
• _______(7) positioning used in many robotic surgeries requires greater vigilance of the patient. IV stops running, what do you do? Think External _______(4) IV.
• Careful endotracheal tube taping and protective foam _______(5) can be placed on the patient’s face for extra security.
  o Pink foam! Always make sure there is a barrier between tube and face.

Answer 17

Answers:
1. access
2. trocars
3. cardiopulmonary resuscitation
4. Jugular
5. padding
6. Undock
7. Steep Trendelenburg

Question 18

Cardiovascular System

• The cardiovascular system is exquisitely challenged during laparoscopy by multiple stressors on preload, inotropy, rhythm, and afterload (Table 44-4 below).
• In patients, the cumulative effect is an increase in…
  o mean arterial pressure (_______1)
  o myocardial oxygen _______(2)
  o systemic vascular _______(3).
• Modifiable factors that affect hemodynamics during laparoscopy include the intravascular volume status of the patient, _______(4), baseline _______(5), and surgical technique.

Answer 18

Answers:
1. MAP
2. demand
3. resistance (SVR)
4. positioning
5. comorbidities

Question 19

Effects of CO2

• Systemic CO2 gas then exerts both direct and indirect effects on the cardiovascular system via adrenergic pathways.
  o Normal range PaCO2 _______(1)
  o Mild hypercarbia (PaCO2 of _______(2)) alters hemodynamics very little,
  o Severe hypercarbia (PaCO2 _______(3)) and acidosis can lead to myocardial depression, dysrhythmias from _______(8)-induced myocardial sensitization, and peripheral _______(4).
• Further complicating the response of the myocardium to transient hypercarbia is the potential for acute elevations in right ventricular afterload from (_______5).
  o TLDR: HIPv → INCR. PA. PRESSURE → RV STRUGGLES TO PUSH AGAINST IT (compensatory mechanism but actually bad 😟)
• The potential hemodynamic effects of severe hypercarbia (decreased heart function and _______(6)) are counteracted by _______(7) nervous system stimulation during laparoscopy, that concurrently produces:
  1. tachycardia
  2. increased MAP
  3. vasoconstriction from an increase in SVR.

Answer 19

Answers:
1. 35-45 mmHg
2. 45 to 50
3. 55 to 70 mmHg
4. vasodilation
5. hypercarbia-induced pulmonary vasoconstriction (HIPV).
6. vasodilation
7. sympathetic
8. catecholamine
9. hypercarbia

Question 20

Table 44-4 Causes of Hemodynamic Changes during Laparoscopy

Determinants of Blood Pressure in Laparoscopy

• Preload (venous return)
  
  • IVC compression: _______(1) or no change
  • Intra-abdominal organ compression: _______(2) or no change
  • Trendelenburg position: _______(3)
• Cardiac output or inotropy
  
  • Venous return: _______(4) or no change
  • Peripheral Vasoconstriction: _______(5) or no change
• Rhythm (brady- or tachyarrhythmia)
  
  • Hypercapnia/acidosis: _______(6) or no change
  • Hypoxia: _______(7) or no change
  • Peritoneal irritation: _______(8), ↓ or no change
• Afterload and MAP
  
  • Hypercapnia/acidosis: _______(9), ↓ or no change

*Autonomic nervous system stimulation and neurohumoral factors, such as catecholamines, vasopressin, and cortisol, released during laparoscopy contribute to physiologic changes. IVC, inferior vena cava; MAP, mean arterial pressure.

Answer 20

Answers:
1. ↑ (Increase)
2. ↑ (Increase)
3. ↑ (Increase)
4. ↑ (Increase)
5. ↑ (Increase)
6. ↑ (Increase) or no change
7. ↓ (Decrease) or no change
8. ↑ (Increase), ↓ (Decrease)
9. ↑ (Increase), ↓ (Decrease)

Question 21

Effects of CO2

The peritoneum and abdominal viscera are highly innervated by autonomic nerve fibers.

• Stimulation of these autonomic pathways during pneumoperitoneum, typically results in
  o _______(1) nervous system activation
  o catecholamine release
  o activation of the renin–angiotensin (RAAS)
  o release of the neurohypophysial hormone _______(2)
  ■ This potent endogenous hormone can cause intense vasoconstriction, an increase in MAP, and increases in left ventricular afterload.
  o _______(4) ventricular wall tension and myocardial work needed to maintain intraventricular pressure and cardiac index (CI), respectively, are raised with significant increases in _______(3).
  ■ Major stress on the heart!

Answer 21

Answers:
1. sympathetic
2. vasopressin
3. SVR (Systemic Vascular Resistance)
4. Left

Question 22

Special Considerations

• Intravascular volume status an important modifier of the _______(5) effects of pneumoperitoneum.
  o In instances where low right atrial pressures reflect low cardiac filling volumes, an increase in Intraabdominal Pressure can result in compression of the _______(1) (IVC), causing a decrease in venous return and cardiac filling.
  o _______(6) can prevent this!
• Steep Trendelenburg positioning during pneumoperitoneum may _______(2) venous return and cardiac filling.
• In contrast, reverse Trendelenburg position during pneumoperitoneum can result in an increase in _______(3) and minor reductions in CI that are soon reversed.
  o Initiating insufflation while supine and maintaining IAP within the recommended range (_______(7) mmHg) can minimize any reduction in preload.
  o Nonetheless, extremely high IAP (>15 mmHg), in addition to hypovolemia, can result in severe compression of the venous system, as well as a perilous reduction in venous return and cardiac filling. → _______(4) collapse!
  ■ DO A FLUID CHALLENGE → 250 CC BOLUS AND SEE HOW THE PATIENT RESPONDS

Answer 22

Answers:
1. inferior vena cava
2. Increase
3. SVR (Systemic Vascular Resistance)
4. CV (Cardiovascular)
5. mechanical
6. Volume
7. 12 to 15

Question 23

Special populations

Special populations

• It is hypothesized that the morbidly obese better tolerate insufflation because of an intrinsically _______(5) IAP at _______(1) compared with nonobese patients.
• Geriatric patients can generally tolerate minimally invasive surgery.
  
  • However, complex hemodynamic changes in elderly patients with cardiovascular disease may be significant during pneumoperitoneum, despite a lack of observable _______(6) by electrocardiogram (aka Despite a LACK of EKG Changes)
  • In geriatric patients with at least _______(2), the initiation of pneumoperitoneum in the supine position results in an _______(7) in SVR, a _______(8) in ejection fraction (EF), and CI.
    
    • Preload and left ventricular stroke work index (LVSWI) remain _______(9).
    • Trendelenburg positioning increases preload, EF, and CI.
    • Return to _______(10) positioning with desufflation decreases SVR below baseline and increases EF, CI, and LVSWI—all above baseline
• In patients with significant pulmonary hypertension or right ventricular failure, ventricular function may be strained in the setting of changing _______(11) and pulmonary vascular resistance (PVR).
  
  • Acute increases in preload can strain an already stressed right ventricle.
    
    • _______(3) in a patient with pulm. Hypertension can be bad
      -_______(12) can lead to increased pulmonary vasoconstriction and increased right ventricular afterload, in addition to impaired inotropy.
  • Significant volume loading of a dilated right ventricle can in turn compress the _______(13) ventricle through the mechanism of ventricular _______(4) leading to reduced global ventricular function.

Answer 23

Answers:
1. 9 to 10 mmHg
2. 1 cardiac risk factor
3. trendelenburg
4. interdependence
5. elevated
6. myocardial ischemia
7. increase
8. reduction
9. unchanged
10. supine
11. preload
12. Hypercarbia and acidosis
13. left

Question 24

The type of surgical procedure may also influence the degree of hemodynamic derangement.
- Surgical disruption of the esophageal hiatus during _______(1) may increase
_______(4) pressures, resulting in a significant reduction in _______(2).
- Fundoplication surgery wraps the upper stomach around the lower esophagus
■ _______(3)

Answer 24

Answers:
1. laparoscopic fundoplication
2. CI (Cardiac Index)
3. google (This appears to be an editing or note-taking artifact and not part of the educational content)
4. mediastinal and pleural

Question 25

Table 44-5. Did not mention this table but an easier summary. - STUDY Table 44-6 Causes of Severe Hypercarbia during Laparoscopy - STUDY Hypercarbia routinely develops in all patients from the absorption of intraperitoneal CO2 into the circulatory system (Table 44-6). - 20x more _______(1) than oxygen. - The concentration gradient that develops preferentially drives CO2 from the pulmonary capillaries into the alveolar network, where it is removed during exhalation and measured by capnography as _______(2) (EtCO2). - Exhaled CO2 and the degree of gas absorption vary based on the route of insufflation, preoperative comorbidities, and acute intraoperative pathology. Extraperitoneal insufflation (nephrectomy, lumbar sympathectomy, adrenalectomy, inguinal hernia) may result in a _______(3) CO2 elimination than during intraperitoneal insufflation, due to a greater likelihood of _______(4). - They do not affect respiratory systems as much. (Think away from lungs)

Answer 25

Answers: 1. diffusible 2. end-tidal CO2 3. higher 4. tissue gas accumulation

Question 26

Respiratory System cont. Hypercarbia in Laparoscopy: @ 47:09 - Hypercarbia is _______(3) but usually not clinically significant in healthy patients. - Hypercarbia results from _______(2) absorption from the peritoneal cavity and reduced ventilation. - Normalization is possible through increased _______(1) and tidal volume (hyperventilation). Excessive CO2 Absorption - CO2 venous embolism - Subcutaneous emphysema - Capnothorax (CO2 pneumothorax) - Capnomediastinum - Capnopericardium Excessive CO2 Production - Hypermetabolic conditions (e.g., fever, malignant hyperthermia) - Morbid obesity Inadequate CO2 Removal - Hypoventilation - Endobronchial intubation - Atelectasis - Cardiogenic shock - Exhausted CO2 absorber

Answer 26

Answers: 1. respiratory rate 2. CO2 3. common

Question 27

Subcutaneous Emphysema in Laparoscopic Surgery - Introduction of CO2: - CO2 gas may accidentally infiltrate _______(1), _______(2), or _______(3), leading to subcutaneous emphysema. - Risk Factors: - Operative time over _______(4). - _______(5). - Lower _______(6). - _______(7) patient age. - Higher _______(8) (IAP). - _______(9) inflation flow rates. - _______(10) surgery. Clinical Signs: - Sudden or persistent _______(1). - Acute _______(2) may indicate subcutaneous emphysema or capnothorax. Management: - Peritoneal _______(3) typically resolves the issue. - _______(4) should be at a reduced IAP if necessary. Postoperative Care: - Generally supportive. - CO2 usually reabsorbed within 24 hours. - Maintain oxygen therapy if there's concern for ongoing _______(1). - Monitor for signs of _______(5) and check _______(6) for acute respiratory acidosis.

Answer 27

Answers: sq emphysema factors 1. subcutaneous 2. preperitoneal 3. retroperitoneal spaces 4. 200 minutes 5. Multiple surgical ports 6. BMI 7. Older 8. intra-abdominal pressure 9. High 10. Nissen fundoplication Answers: mngmt subq emphysema 1. hypercarbia 2. hypotension 3. desufflation 4. Reinsufflation 5. somnolence 6. arterial blood gas

Question 28

Complications and Ventilation-Perfusion Relationship and Pneumoperitoneum: @ 48:24 - Both conditions exacerbate ventilation and gas exchange issues during laparoscopy. - Morbid obesity increases inspiratory resistance and reduces _______(1) (FRC). - _______(2) heart issue? - _______(4) complicates the intraoperative management due to compromised pulmonary function. - Exact impact on _______(5) ratio during laparoscopy remains uncertain. - Porcine studies suggest _______(6) occurs post-pneumoperitoneum, potentially improving arterial oxygenation (PaO2). - Hypoxic pulmonary vasoconstriction may lead to redistribution of blood flow away from _______(3) (collapsed) areas, hence improving oxygenation. - These physiological changes may necessitate alterations in anesthetic management to ensure adequate oxygenation and ventilation.

Answer 28

Answers: 1. functional residual capacity 2. CHF 3. atelectatic 4. COPD 5. V/Q 6. hypoxic pulmonary vasoconstriction

Question 29

Acute Cardiovascular Complications During Laparoscopy - Hypertension during Laparoscopy: - Occurs with initial insufflation; splanchnic blood displacement _______(1) preload and cardiac output. - Catecholamine _______(2) increases afterload. - Hypotension Mechanisms: - Low cardiac output due to _______(3) stimulation. - Impaired venous return from insufflation. - _______(4) and _______(5) affect preload. - Hypercapnia Consequences: - _______(6) pulmonary vascular resistance (PVR), impacting preload in certain cardiac conditions. - Arrhythmias: - _______(7) linked to catecholamine release and hypercapnia. - Bradycardia may result from a _______(3) reflex during peritoneal stretching. - Cardiac Arrest: - Can be triggered by a vasovagal reaction to rapid peritoneal distention. - Management: - Acute hypertension may be managed by deepening anesthesia; vasodilators for severe cases. - Hypotension responses include reducing anesthesia depth, fluid administration, lowering insufflation pressure, and using vasopressors. - Peritoneal deflation and slower, lower-pressure re-insufflation may be necessary for treatment-resistant hypotension. - Reversal of position and slower, lower-pressure re-insufflation may be necessary for persistent hypotension. - Persistent hypotension might necessitate abdominal decompression and investigation for conditions like **hemorrhage or capnothorax.**

Answer 29

Answers: Acute CV collapse 1. increases 2. surge 3. vagal 4. Positive pressure ventilation 5. Reverse Trendelenburg 6. Raises 7. Tachyarrhythmias

Question 30

Complications Related to Laparoscopic Surgery: Intraoperative Intra-abdominal Injuries - Primary Causes of Complications: - Over ___(a)% stem from entry techniques: Veress needle and primary trocar insertion. - Major Vascular Injuries: - Though rare, they have high mortality. - At-risk vessels during midline entry: - _______(1) aorta - _______(2) vessels - _______(3) vena cava - At-risk vessels during off-midline entry: - _____ and _______(4) mesenteric arteries - _____b. artery - Small vessels of the ____c. wall - Occult Bleeding: - Significant bleeding may not be immediately evident. - High vigilance required during the procedure. - Anesthesiologist's Role: - Must be ready for rapid transition to ___d for bleeding control. - Manage hemodynamic instability and potential hemorrhagic shock.

Answer 30

Answers: intra abdominal injuries a. 50 1. Abdominal 2. Iliac 3. Inferior 4. Superior; inferior b. epigastric c. abdominal d.open laparotomy

Question 31

Regional Perfusion Effects During Laparoscopy: @ 50:56 - _______(4) blood flow decreases due to external compression from pneumoperitoneum and systemic _______(1) caused by _______(2) hormone release. - This is a transient effect with limited clinical significance in healthy patients. - _______(3) vein flow is known to be reduced by increased intra-abdominal pressure (IAP). - Cardiovascularly compromised patients might experience mesenteric ischemia due to diminished mesenteric flow during pneumoperitoneum. - In healthy individuals, splanchnic vasodilation from absorbed CO2 may counteract reductions in mesenteric blood flow. - Extra caution is advised for patients with pre-existing gastrointestinal conditions.

Answer 31

Answers: 1. vasoconstriction 2. neuroendocrine 3. Hepatic 4. Splanchnic

Question 32

Renal Considerations and Acute Kidney Injury Risks: @ 52:30 - Renal function is generally reduced during pneumoperitoneum. - IAP and neurohumoral responses to pneumoperitoneum contribute to decreased renal blood flow, _______(1), and urine output. - Preoperative risk factors, like existing renal dysfunction, elevate the risk for postoperative AKI. - Bariatric surgery patients with higher BMI and _______(2) (both insulin- and noninsulin-dependent) are at increased risk for AKI within 72 hours post-surgery. - The use of intermittent sequential pneumatic compression devices during bariatric surgery may _______(3) renal blood flow and urine output. - While improvements in renal perfusion have been observed, the underlying mechanisms and the role in AKI prevention are not fully understood. Cerebral Perfusion Dynamics in Laparoscopy: @ - Both intracranial pressure and cerebral perfusion are increased in Trendelenburg position and with pneumoperitoneum. - Likely reasons include reduced cerebral venous outflow and increased cerebral blood flow from _______(4). Table 44-8 Causes of Regional Perfusion Changes during Laparoscopy - STUDY

Answer 32

Answers: 1. glomerular filtration rate 2. diabetes 3. enhance 4. hypercarbia

Question 33

Gastrointestinal and Urological Injury Concerns in Laparoscopy - Injuries During Laparoscopy: - Gastrointestinal and urological injuries can occur during abdominal entry and intra-abdominal phases. - Bowel injuries, though _______(1), lead to significant morbidity and mortality. - High laparotomy rates result from such injuries. - Unrecognized Injuries: - Many intestinal injuries are not identified intraoperatively. - Leads to a high risk of postoperative intra-abdominal _______(2). - _______(3) is a common cause of death post-laparoscopy. - Preventive Measures: - Routine deflation of the stomach with an _______(4) tube is advised. - Reduces the risk of gastric injury during _______(5) trocar placement. - Urological Injury Indicators: - Bladder perforation and ureter injuries may manifest as: - _______(6) urine output. - _______(7).what kind of urine? - Rarely, _______(8) (air in urine). Diagnostic Tools: - Methylene blue administration: - Intravenously: Rapid kidney reach, abdominal appearance indicates _______(1). - Methylene Blue: Very quickly reaches the Kidneys - so if you give IV, it will appear in the abdomen if there is a _______(2). If not, it will only turn the foley _______(3). - "Baby Formula" at 1:03:00 - Via Foley catheter: Confirms urinary tract _______(4). "It's ok if it gets into a body cavity if there's a perforation because baby formula is _______(5)" Postoperative Signs of Injury: - Hemodynamic instability or gross hematuria postoperatively warrants immediate evaluation for hidden injuries. - Indicators of serious complications: - Internal _______(6). - Fecal contamination in the _______(7).

Answer 33

Answers: indicators 1. infrequent 2. sepsis 3. Sepsis 4. orogastric 5. left upper 6. Low 7. Hematuria 8. Pneumaturia Answers: diagnostic tools 1. perforation 2. perf 3. blue 4. patency 5. sterile 6. bleeding 7. peritoneum

Question 34

Monitoring During Laparoscopic Surgery: @ 53:12 - Central venous pressure (CVP) monitoring's reliability is _______(1). - Increased intraabdominal pressure from CO2 insufflation and steep Trendelenburg position affects CVP readings. Nitrous Oxide (N2O): 53:55 - N2O use during laparoscopy is _______(2) due to its potential to expand air-filled spaces. - N2O can diffuse into the bowel, theoretically causing adverse pressurization. - Clinical evidence suggests _______(3) significant intestinal distension from N2O use during laparoscopy. - Some anesthesiologists avoid N2O to reduce the risk of postoperative nausea and vomiting (PONV). - PONV risk is perceived to be higher with N2O, especially in _______(4). - However, the risk of PONV when using N2O for laparoscopic procedures is not definitively higher when compared to non-N2O anesthesia.

Answer 34

Answers: 1. questionable 2. debated 3. no 4. young females

Question 35

Pharmacologic Adjuncts in Laparoscopic Surgery: @ 54:50 - Laparoscopy offers less postoperative pain than open surgery; adjuncts aim to reduce intraoperative sympathetic stimulation and enhance recovery. - Remifentanil: - Attenuates sympathetic response during pneumoperitoneum. - Short-acting nature limits prolonged respiratory depression. - Dexmedetomidine: - Decreases intraoperative fentanyl requirements. - Reduces incidence of PONV and PACU duration post-bariatric surgery. - Lidocaine Infusion: - Provides early postoperative analgesia and _______(1) GI motility recovery. - Utilized during abdominal laparoscopic procedures. - Local Anesthetics: - Administered as wound infiltration or intraperitoneal instillation for preemptive analgesia. - Demonstrated improvement in early postoperative pain scores. - _______(2) may benefit procedures with longer incisions. - Transversus Abdominis Plane (TAP) and Quadratus Lumborum (QL) Blocks: - The H-Meister has endorsed this as effective analgesic techniques for laparoscopic surgery.

Answer 35

Answers: 1. hastens 2. Continuous infusion

Question 36

Neuromuscular Blockade in Laparoscopic Surgery: @ 56:20 - Neuromuscular blocking agents (NMBAs) facilitate surgical exposure by relaxing muscles during pneumoperitoneum. - Optimal depth of neuromuscular blockade (NMB) is debated - Goal is to balance improved surgical conditions against risks of postoperative residual paralysis. - Surgeon satisfaction: - Higher with deep neuromuscular blockade compared to lighter levels. - Suggests better surgical exposure and working conditions. Mechanical Ventilation Strategies in Laparoscopy: @ 56:39 - Ventilation Modes: - _______(4) ventilation ensures constant tidal volume despite variable peak airway pressures. - _______(5) ventilation maintains constant peak airway pressure with variable tidal volumes. - Effects of Patient Positioning: - Steep Trendelenburg in VC: - Increases peak airway pressure. - _______(2) lung compliance. - Steep Trendelenburg in PC: - _______(3) tidal volume. - Reverse Trendelenburg: - _______(6) peak airway pressure with VC. - _______(7) tidal volume with PC.

Answer 36

Answers: 2. Decreases 3. Decreases 4. VC 5. PC 6. Decreases 7. Increases

Question 37

Mechanical Ventilation Strategies in Laparoscopy: @ 56:39 Ventilation Adjustments: - Compensatory hyperventilation may counteract hypercarbia. - Healthy patients might need minute ventilation increased by approx. _______(4) above baseline during laparoscopic cholecystectomy to normalize hypercarbia. - PEEP application: - _______(1) oxygenation and V/Q matching. - May be particularly beneficial during prolonged pneumoperitoneum. - Especially if hypercarbic - Alveolar recruitment maneuvers (RM) with PEEP: - Can prevent ventilator-induced lung injury. - Crucial for obese patients to maintain alveoli open. Lung-Protective Ventilation: - Draws from intensive care management of ARDS. - Employs low tidal volumes (_______(2) cc/kg of ideal body weight). - Utilizes optimized PEEP levels (_______(3) cm H2O or higher). - Incorporates periodic RM. - Aims to prevent ventilator-induced lung injury.

Answer 37

Answers: 1. Enhances 2. 6-8 3. 5-10 4. 25%

Question 38

Management of Body Temperature in Laparoscopy: @ 57:50 - CO2 Insufflation: - CO2 is stored as a cold liquid; upon expansion to gas, it cools the surgical site. - Cold, dry CO2 potentially exacerbates _______(1) heat loss. - Temperature Preservation Techniques: - Active warming of insufflated CO2: - Use _______(2) heating devices to warm and humidify CO2. - Alternative warming methods: - a trash bag over the patient’s head if specific warmers are unavailable. - Application of Bair Hugger: - Utilize for patient warming, preferably a lower body Bair Hugger for increased surface area coverage and heat provision.

Answer 38

Answers: 1. convective 2. inline