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FLS
What are the laparoscope diameters? - answer2-10mm Which degree scope is best for a field in line with port? - answer0 degree How to prevent fogging of scope? - answer Use anti fog solution or put scope in hot water/hot bath What is the most commonly used light source? - answer300 W Xenon lamp What if there is initial low pressure and high flow rate at entry? - answer Leak in insufflator circuit, make sure everything plugged in correctly Benefits of monopolar - answer Tissue is heated quickly, less thermal damage/coagulation Monopolar voltage/frequency - answer Low voltage/High frequency What does coagulation mode do? – answer Repid surface heating with shallow depth of necrosis, intermittent wave form with higher voltage Risk of monopolar - answer Current can be diverted through unintentional pathways, leading to inadvertent tissue injury. Don't use hybrid ports that mix metal with plastic Why do you need a grounding pad for monopolar? - answerCapacitative coupling - transfer of energy between two conductors separated by an insulator, transfer to passive electrode. Can release with tissue injury, but no issue if ground plate is working as capacitor can't store the charge Benefits of bipolar - answerlower energy, producing less lateral tissue damage and necrosis. Don't need a grounding pad Risk of bipolar - answerRisk of cutting patient vessels before adequate sealing, and device doesn't work if there is metal between the jaws Risk of ultrasonic dissection (harmonic) - answerActive blade can injure something due to high frequency (50mHz) Discontinue aspirin day of surgery? - answerNo How to enter in patient with bowel obstruction? - answerDirect visualization
Cut vs Coag - answercut - heat tissue quickly to convert cell water to steam, lysing the cell Coag - heat more widely dispersed, less cutting action smaller tissue area, greater current density and faster heating - answere.g. Bovie tip Cut mode - answer- Low voltage
- High frequency
- Continuous waveform
- Heats tissue quickly; cell water converts to steam and causes cell to explode Coagulation mode - answer- High voltage
- Low frequency
- Intermittent waveform
- Rapid tissue heating, shallow depth of necrosis
- Non-contact: relies on sparking to tissue Capacitive coupling - answerTransfer current from active electrode through insulation to passive electrode- electrode to plastic part another LSC instrument
- if constant contact w/ tissue will not store energy and no injury Direct coupling - answermonopolar instrument in direct contact w/ metal portion of another instrument Besides capacitative coupling and direct coupling, other hazards of electrocautery - answer- Current diversion
- Narrow return circuit Bipolar - answer- forceps w/ two twins (one active other return)
- no pt return electrode required)
- no capacitative coupling
- works in "wet" operative field
- less thermal spread compared to monopolar bipolar seals vessels up to _____ mm in diameter - answer7 mm ultrasonic coagulation shears seals vessels up to ____ mm in diameter - answer5 mm ultrasonic coagulation shears - answer- combo compression and friction
- ONE active blade
- monopolar capacity w/ the one blade
- no capacitative coupling
- high power (MAX): cut
- low power (MIN): coag How many days prior to surgery does warfarin has to be discontinued? - answer3 days
- Easily eliminated (diffusion coefficient 20x CO2)
- Suppresses combustion
- Readily available
- Inexpensive Chemical effects of CO2 - answer- Increase arterial and end tidal CO
- Decrease serum pH w/ greatest change in first 20 min (SS after 1h) Pressure effects of CO2 - answerPulm
- Reduced functional residual capacity
- Reduced pulmonary compliance
- Increased peak airway pressure CV
- Increase preload and afterload, DECREASE CO
- Brady, PVC
- increased VC resistance and decrease venous flow, theoretically increase risk VTE Renal
- intraop oliguria d/t increased intraabd pressure, decreased renal BF Shortly after insufflation pt becomes hypotensive, bradycardic w/ decreased UOP, what to do? - answerExperiencing vagally-induced bradycardia
- STOP, desufflate immediately
- check adequate relaxation
- check intravascular volume status
- check other causes of hypotension (e.g. bleeding)
- once stabilized and r/o other causes, reinsufflate slower and w/ lower pressure During the case pt suddenly becomes hypotensive, tachycardic. You note JV distention and audible mill wheel murmur on cardiac auscultation. What to do? - answerCV collapse from gas embolism!
- place pt in trendelenberg position, left-side down
- rapid IVF
- central line placement to back up embolus in right heart chambers LSC examination of small bowel - answerplace monitors- one near head (ligament treitz), one near feet (ileocecal valve place ports along left abd IN SBO pt, start at ILEOCECAL valve (most distal, should be most decompressed) FNA uses ______G needle - answer20-22 G Core biopsy uses a _____G needle - answer14-16 G LSC suturing technique - answer- ports at least 10 cm apart to allow intracorporeal knot tying
- 10-12 mm trocar accommodates standard SH needle
Length of suture for intracorporeal knot tying - answer6 inches (15 cm) Length of suture for extracorporeal knot tying - answer30 inches (76 cm) 2-2.5 mm staples used for - answer- white/grey in color
- vascular, thinner tissue 3-3.5 mm staples - answer- blue
- for majority GI tract 4-4.5 mm staples - answer- green
- for distal stomach, thickened portions of GI tract Monopolar cautery - answer- smaller vessels, slow rate bleeding, need relatively dry operative field Days until full diet tolerated - answer1-2d for fundoplication 3-6d for colon resection Postop - vascular injury smaller vessels - answer- usu superior/inferior epigastric vessels, mesenteric arteries/veins --> abd wall or peritoneal hematomas.
- Surgery if con't bleeding, infxn, HD instability In the event of a blank screen, which is NOT a likely problem site? - answerFRED anti- fog solution If the laparoscopic view of the operative field is reduced in size, thus compromising proper exposure of the operative field, which of the following should be immediately checked? - answercheck the insufflator control panel to determine the cause of the loss of working space in the operative field all of the following are pre-operative checks except? - answercheck for adequate muscle relaxation. Correct answers include checking that a spare CO2 tank is in the OR, availability of ancillary equipment, and all power sources are connected and appropriate units are switched on During monopolar electrosurgery, the method of heating tissue quickly, converting all water to steam and causing the cell to explode is descriptive of which of the following: - answercutting mode click on the point that is in danger of thermal burn if a monopolar electrode is applied to the end of the appendiceal stump? - answerthe diameter at the ligature is half that at the stump, so the current density will be 16X greater
previous hysterectomy through midline incision, previous Crohn's disease with enterocutaneous fistula, and previous umbilical hernia repair what is the best area for alternate Veress needle insertion relative to a midline vertical scar? - answerPalmer's point (LUQ) Extra caution must be taken when placing the Veress needle and primary trocar in the midline such as at the umbilicus due to concerns with injury to what organ? - answerAorta (and IVC) When should a check for venous bleeding be performed? - answerduring final abdominal inspection, while releasing abdominal pressure, and during trocar removal once the operative procedure is finished, the surgeon should check which of the following areas before exiting the abdomen? - answerthe operative field, the dependent portions of the abdomen away from the field of view at the operative site, and the abdominal wall a each port site once the port has been removed What is the reason fascia at trocar sites is sutured (closed)? - answerprevention of hernia Why is CO2 the preferred gas for establishment of pneumoperitoneum? - answerrapidly absorbed Easily eliminated Supresses combustion Readily available Relatively inexpensive CO2 pneumoperitoneum chemical effects - answerIncrease arterial CO2 concentration Increase end tidal CO Decrease serum pH Vigilant moitoring in patients with severe cardiopulmonary disease --> end-tidal CO2 monitoring essential --> greatest change in first 20 minutes CO2 pneumoperitoneum pressure effects - answerCardiovascular Pulmonary Renal Integrated with chemical effects Pulmonary physiology with pneumoperitoneum - answerIncrease minute ventilation to eliminate absorbed CO Reduced functional residual capacity (FRC) Increase peak airway pressure Reduced pulmonary compliance Reduced diaphragmatic excursion
Additional CHEMICAL cardiovascular effects of pneumoperitoneum - answerSystemic vascular changes Cerebral auto-regulation of blood flow Vagal responsiveness to reverse Trendelenburg position Additional PRESSURE cardiovascular effects of pneumoperitoneum - answerLower initial insufflation rate and set pressure associated with slightly less postoperative abdominal and shoulder pain Which are the alternatives to CO2 for establishment of pneumoperitoneum? - answerNitrous oxide (N2O) Air Helium Argon Nitrous Oxide BENEFITS as insufflation gas compared to CO2 - answerLess acid-base disturbances May be better tolerated in patients with severe cardiopulmonary disease Tolerated relatively well without general anesthesia Slightly less postoperative pain Nitrous Oxide RISKS as insufflation gas compared to CO2 - answerFire hazard if using electrocautery in the presence of open bowel (supports combustion) Inert gases (argon & helium) BENEFITS as insufflation gas compared to CO2 - answerNo hypercarbia and acidosis Inert gases (argon & helium) RISKS as insufflation gas compared to CO2 - answerLess soluble in blood --> increase risk gas embolism (extraperitoneal gas extravasation) more expensive Insufflators designed for their use not readily available Cardiovascular changes with pneumoperitoneum - answerIncreased preload and afterload Decreased cardiac output --> hypotension, cardiac arrhythmia, decreased urine output, increased end tidal CO (signs and symptoms of reduced tissue perfusion) Cardiac arrhythmias due to pneumoperitoneum - answerSinus tachycardia Premature ventricular contractions Bradycardia How much does venous flow rates drop during pneumperitoneum? - answer26-39% What is the incidence of VTE following laparoscopic colocystectomy? - answer0.5%
what variable will be decreased by pneumoperitoneum? - answercardiac index What are the most common sources of unrecognized bleeding? - answerTrocar injury of abdominal wall vessels Injury to vessels or organs away from the operative field (eg liver, spleen) Tamponade of venous bleeding (by pneumoperitoneum) Why is recommended to actively evacuate as much of the pneumoperitoneum as possible at the conclusion of the intraabdominal portion of the procedure? - answerHelp reduce postoperative pain In what age group port sites 5mm or smaller require closure of the fascia? - answerPediatric Abdominal wall closure of the port sites can be accomplished using... - answerOpen techniques Laparoscopic-assisted techniques Entirely laparoscopic techniques When should a check for venous bleeding be performed? - answerDuring final abdominal inspection, while releasing abdominal pressure, and during trocar removal Once the operative procedure is finished, the surgeon should check which areas before exiting the abdomen? - answerOperative field, dependent portions of the abdomen away from the field of view at the operative site, abdominal wall at each port site onece the port has been removed what is the correct patient position for diagnostic laparoscopy for pelvic procedure? - answerdorsal lithotomy what is the correct patient position for diagnostic laparoscopy for appendectomy? - answertrendelenburg which of the following pathology can be diagnosed laparoscopically? - answerCrohns, traumatic diaphragm injury, and ovarian cyst what are of the abomden is best for placement of ports to view kidneys and adrenal glands? - answerUpper abdomen (epigastric, RUQ, LUQ) retraction of the uterus can be accomplished by? - answertransvaginal manipulator, blunt grasper, laparoscopic retractor, and suture placed through abdominal wall In general, if an ovarian cyst is larger than 5cm or has complex internal US findings, biopsy should be done by? - answeroophorectomy
general principles of successful laparoscopic tissue biopsy include all of the following EXCEPT: - answerremove biopsy specimen with an energy source to avoid bleeding (correct answers include avoid contacting tissue of extraction site with specimen, excisions biopsy of small lesions is appropriately, generally avoid biopsy of fluid filled liver lesions) which of the following about intracorporeal suturing is not true? - answergrasping the needle is the ideal way to control it when transporting the suture in and out of the abdomen true statements include: the ideal suture length is about 6inches, the ideal orientation for suturing is from 3 o'clock to 9 o'clock, pulling the needling along its arc through the tissue will minimize damage general principles regarding hemostasis during laparoscopy include all of the following EXCEPT: - answerapplying vascular clips to the general area is usually sufficient correct statements include: it is best to specifically identify the bleeding point, avoiding injury to adjacent structures is important, adding extra ports may be necessary, conversion to open may be necessary all of the following are generally true regarding port site bleeding EXCEPT - answerthere is no need to remove ports under direct visualization correct answers include: external hemorrhage may require extension of skin incision, internal hemorrhage may not be present while port is in place, internal hemorrhage may not be visible from skin incision, ports placed through the rectus muscle should be done under direct laparoscopic visualization when compared to monopoly cautery, bipolar cautery affords all of the following advantages EXCEPT - answermore beneficial for capillary sized vessels correct answers include: useful for larger vessels, functions better in "wet" operative field, has advanced computer devices available,e has less lateral thermal spread when dividing a large vascular structure, which of the following is true? - answerthe surgeon must be prepared to immediately intervene in case vascular control is lost for how many days postoperatively will shoulder pain secondary to diaphragmatic irritation typically persist? - answer1-3 days which of the following classes of medications should NOT be considered to treat a patient with postoperative nausea and vomiting? - answermorphine sulfate
Upper Abdominal Laparoscopy - Position and equipment - answerArms can be out on arm boards Reverse Trendelenberg position (need foot board and leg strap) May need:
to retract liver (retractor and holder) biopsy and hemostasis tools Ultrasound or C-arm Suturing capability Diagnsotic laparoscopy for suspected pelvic pathology - answerArms tucked Trendelenberg position Plan for retraction of uterus: uterine manipulator, laparoscopic retractor, suture retraction to abdominal wall Plan for biopsy (equipment, instruments, hemostasis, pathologist consultation) Small intestine runs from the LUQ at the _____ to the RLQ at the _____ - answerLigament of treitz; ileocecal valve Examination of the small intestine - answerPosition 2 monitors - one near head, one near feet (best monitor position are by the Lt shoulder and Rt hip) Place ports along Lt abdomen if feasible Keep instrument tips in field of view as much as possible Use graspers designed for atraumatic handling Avoid torquing bowel wall with graspers Handle mesenteric fat rather than bowel wall when possible Handle dilated bowel with extreme caution Start at cecum and work proximally Diagnostic laparoscopy for small bowel obstruction - answerInitial entry under direct visualization Begin examination of small bowel distantly (decompressed) start at the ileocecal valve with a relative collapsed bowel Manipulate dilated small bowel with extreme caution Perform instrument exchanges carefully due to decreased working space Diagnostic Laparoscopy for Retroperitoneal Structures ABOVE aortic bifurcation - Position - answerLateral position Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation - Position - answerTrendelenburg with or without lithotomy What is the area for best placement of ports to view the kidneys and adrenal glands? - answerAlong the costal margin Mention the biopsy methods used in laparoscopy - answerPeritoneal washing and scrapings
FNA
Core needle biopsy (a form of incisional biopsy) Incisional (wedge) biopsy Excisional biopsy FNA - answer20-22 gauge needle Need sufficient needle length (eg. spinal needle) Plunger with finger loops os helpful Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation - Position - answerTrendelenberg with or w/o lithotomy Core needle biopsy - answer14-18 gauge needle Most commonly used for biopsy of the liver More at risk for bleeding Biopsy forceps - answerJaws have a cutting rim and are hollowed out in the center to capture and prevent crushing the tissue sample Incisional - larger lesions Excisional - small lesions Wedge biopsy - answertissue sampling utilizing a scalpel, scissors or stapling device Peritoneal washing - answerShould be obtain early in staging laparoscopy infuse at least 100cc of 0.9NSS (unless abundant ascites present) +/- mixed sample with a heparin solution for proper cytologic examination Biopsy of peritoneal lesions - answerSmall Excisional biopsy of a single small lesion
Biopsy forceps Grasper and scissors Incisional biops of larger lesions Biopsy forceps Grasper and scissors Able to remove through 5 or 10 mm port Lymph node biopsy - answerExcisional biopsy Hemostasis Energy source - careful use during biopsy Topical hemostatic agent - useful after excision Removal Smaller nodes - 10-12 mm port Larger nodes - specimen retrieval sac Liver Biopsy - Parenchymal disease (cirrhosis) - answerCore needle biopsy
