what is important to document from patients history before surgery?
- anesthesia problems
- prosthetics
- implants
- radiation sites/ports
- prior surgery
- lung/heart history
What medications is good to know?
- steroids/immunosuppresseive drugs (stress steroids?)
- lung/heart meds
- anticoagulants (dc at least three days before)
NSAIDs (don’t need to DC aspirin before lap surgery)
PE should include
VS, chest/cardiac exam, abdominal exam (incisions, scars, hernias, masses, organomegaly…)
ASA classifications
- no physiologic/biochemical/psychiatric disturvances
- mild/mod systemic disease
- severe systemic disease that limits activity
- severe systemic disturbances that limit the patient and are life threatening with and without surgery
- moribund patient, little chance of survival, surgery as last resort
what ASA classes may not be candidates for lap surgery?
4 and 5
due to cardiopulmonary requirements of pneumoperitoneum, like decreased venous return and diaphragmatic excursions and need for hyperventilation
what needs to go into informed consent?
enough information on condition, proposed treatment and alternatives, expected benefits
includes need for GETA and possible need for open surgery
what do you need to do for obese pts?
trochcar insertion: perpendicular to abdominal wall, may need longer ones (>100mm)
- consider placement of spinal needle first to define intraop penetration point
tricks to placing trochars in thin patients
- elevate abdominal wall
- place verses needle away from middle one near coastal margin
- use open approach or optiview
**these also help if patient has had previous abdominal surgery
absolute CIs to lap surgery
- inability to tolerat laparotomy
- hypovolemic shock
- lack of proper surgeon training
- lack of institutional support
relative CIs to lap surg
- inability to tolerate GETA
- long standing peritonitis
- large abdominal/pelvic mass
- massive incarcerate ventral/inguinal hernias
- severe CP disease/intolerance of proper positioning
preop precautions:
1. visceral arterial aneurysm
2. scars
3. hx of peritonitis
4. umbilical abnormalities
5. hepatosplenomegaly
6. hepatic cirrhosis
7. presence of intestinal obstruction
8. pregnancy
9. thin
- risk of injury with trocar placement
- adhesions
3, adhesions - avoid blind techniques of initial access at umbilicus (ensure no mesh)
- risk of injury or poo exposure
- bleeding or post op ascites
- increased risk of enterotomy, limits vision
- careful of uterus
- less space
relative CIs to: cchole
GB cancer
portal HTN
cirrhosis
acute cholecystitis
mirizzi syndrome
relative CIs to: appy
phlegmon
large abscess
relative CIs to: colon resection
large fixed mass
dense adhesions
massive bowel dilation
T4 tumors
relative CIs to: emergency lap
long standing peritonitis
hemodynamic instability partially correctable with resuscitation
massive bowel dilation
relative CIs to: pelvic lap
large fixed masses
inability to tolerate t berg
relative CIs to: foregut procedures
previous gastric operation (esp GE junction)
heptosplenomegaly
relative CIs to: lap antireflex surgery
esophageal shortening
epithelia dysplasia
previa gastric surgery
liver enlargement
large hiatal hernias
relative CIs to: hernia repair
large, incarcerated hernias
acutely incarcerated hernias requiring bowel resection
need for removal or large prosthetics
need for skin graft removal or large scar revision
what are things commonly mistaken for CIs to laparoscopy?
Diaphragm injury
GI bleed
Perforated viscus
Bowel obstruction
ABD trauma
Ectopic/IU pregnancy
Obesity
COPD
renal insufficieny
what are things commonly mistaken for CIs to laparoscopy?
Diaphragm injury
GI bleed
Perforated viscus
Bowel obstruction
ABD trauma
Ectopic/IU pregnancy
Obesity
COPD
renal insufficiency
when can laparoscopy be used in trauma patients?
- Can be used to detect visceral injuries after penetrating injuries
- Can be used for diagnostic and therapeutic purposes
- To help reduce number of non-therapeutic laparotomies
what trimesters can laparoscopy be used in pregnancy?
all of them
- Tailor initial access based on fundal height
- Use LL recumbent position
- Lower insufflation pressures w/o compromising operative exposure
- Fetal heart monitoring pre- and post- op
how is lap used in peritonitis?
Laparoscopy may be diagnostic or therapeutic
Often have dense inflammatory reactions that require open approach if long standing
