more common veress needle inserted blindly passing through abdominal wall (first trocar) inferior to umbilicus confirmed with saline vs open technique: small incision below umbilicus through skin and fascia (additional trocars added prn)

explain open technique:

open technique: small incision below umbilicus through skin and fascia (additional trocars added prn) not as common vs: closed technique: veress needle inserted blindly passing through abdominal wall (first trocar) inferior to umbilicus confirmed with saline

peritoneal cavity is unsufflated with ______ at the rate: ___ L/min and why this gas?

CO2 4-5L/min easily reabsorded colorless not flammable

Indications and Benefits of Lap:

small incision and scar less p/o: ileus pain pulm implications less blood loss economical and medical advantages

contraindications to lap: 6

bowel obstruction, ileus, peritonitis intraperitoneum hemorrhage diaphragmatic hernia severe cardiopulmonary disease morbid obesity* 3rd trimester prego

p/o pain type:

VISERAL: Bily colic, dulle, ache neck and shoulder: pneumopertitoneum irritates diaphragm residual CO2 (NOT parietal, no abdominal wall sharpness)

Challenges of Lap in OR room:

lights off space of large equipment

lining of the abdominal cavity:

parietal peritoneum

anesthesia considerations of Lap:

pressurized CO2 insufflation : pneumoperitoneum establish and maintained can have profound effects on patient usually GA balanced foley, SCDs PONV prophylaxis ETCO2 req NG/OG to decompress stomach positioning: dependent on procedure

high risk time of insufflation:

established

ET tube considerations with Lap:

positive pressure ventilation increase MV 30% increase RR increase intrabdominal P= regurg risk prevent hypercarbia muscle relaxant: to decrease insuff pressures, prevent movement, communicate with surgeon

LMA considerations with Lap:

15 rule: degree, minutes, ? experienced anes provider careful patient selection correct size surgeon aware TIVA or volatiles

goal of positioning with lap:

gravitational displacement of viscera away from surgical site

lap position for gyn or Colectomy:

head down, trend

head down, TREND: 3 changes: and what procedure

increase: central blood volume and CO decrease: diaphragmatic excursion gyn and colectomy

head up, REVERSE Trend: 3 changes, what procedure:

increase: Pulm dynamics decrease: venous return, CO upper GI, cholescyectomy (with left lateral tilt)

positioning: remember:

gradual position change padding for nerve injury

factors of positioning

degreee of tilt pt age intravascular volume co morbids drugs used ventilation technique

Pulm considerations for lap: diaphragm is displaced ____________

cephalad

Pulm changes with lap:

decrease: compliance, FRC, VC > atelectasis increase: PIP VQ mismatch: shunt: perfusion with no ventilation hypercarbia hypoxia

cardiac: increase to intra-abd pressure with increase compression of:

venous capitance and arterial resistance vessels

minimize cardiac effects to keep pressure at:

12-14 mmHg

minimize cardiac effects by: 4

insufflation slow change position slow head down preop fluids

CO with lap:

may increase due to decrease venous return or decrease 30% (preload)

peritoneal stretch and viscera manipulation can cause:

vagal, Brady, asystole, arrhythmia

how to treat Bradycardia during lap

stop insuff atropine

hypercarbia during lap with stimulate:

SNS tachy, htn, CVP

complications of lap

subQ emphysema pneumomediastinum capnothorax pneumothorax CO2 gas embolism hemorrhage: large vessel injury vasovagal reflex: with light anesthesia viseral injury: by trocar burns increase CO2 causes increase ICP

subQ emphysema

extraperitoneal insuff subcutaneous or retroperitoneal emphysema increase ETCO2 accumulation in fascia and peritoneum could compromise airway OK to extubate if hypercarbia corrected and even with cervial emphysema

pneumo: quick differential diagnosis:

capnothorax alveolar rupture

pneumo/mediastinum

insuff gas > pleural space > congenital hernia > by aorta/esophagus usually resolves uneventfully

capnothorax steps to tx

CO2 in thoracic cavity 1. stop NO 2. confirm with X-ray 3. adjust ventilation to maintain sat 4. apply PEEP 5. decompress with chest tube if req - usually resolves spontaneously in 30-60 min after exsuff 6. continue if pt stable

CO2 gas embolism: why/where, symptoms, tx

rapid insuff= gas lock in vena cava and RA sx: biphasic etCO2 tachy/hypo millwheel murmur and Pulm edema lethal dose of CO2 is 5x of air bc blood carries CO2 well and very soluble 1. stop insuff 2. release pneumo 3. DC NO 4. hyperventilate 100% 5. Durant position: head down left lateral decub to evacuate air from apex of RV 6. CVC to aspirate

other consideration of lap:

risk NV and aspiration decrease UO operator expertise increase time duration money

vasovagal reflex during lap due to:

light anesthesia

hysterectomy: position, risks, treatment of po pain

trend/lithotomy pneumperitoneium only if DX (embolization risk) risk fluid overload and hyponatremia because increase amount fluids used to visualize endometrium NSAID; ketorlac

cholecystectomy: anesth concerns

GA; possible RSI no narcs??, NMB, decompress stomach sphincter of oddi: narcs will spasms relax using: glucagon, NGT, nalazone po pain, NV

inguinal hernia repair: position, type of insuff, risks

supine GA extraperitoneal insuff risk: vagal response to traction pt usually has comorbids unless active male with injury

thorascoscopy: VATS: type of ET, position, risks, po pain

video assisted thoracic sx double lumen ET lateral decub lung deflation: VQ mismatch Aline intercostal block for po pain