Operative Considerations
Name two absolute contraindications to minimally invasive surgery
Severe hemodynamic instability (shock) and lack of experience/training/support
RF current travels through the patient to a dispersive electrode.
RF energy remains between the instrument tips; no dispersive electrode is required.
A piezoelectric disk converts radiofrequency energy into mechanical vibration.
monopolar
bipolar
ultrasonic
Effect on body temperature
hypothermia
Blank video screen
Check for disconnected power cord
§ Check for disconnected video cables
§ Check for blown light source bulb
§ Check for disconnected light cable (at scope or light source)
what electrolyte is important to replace in intubated patients
phos
What gas is used for insufflation and why? (four reasons)
CO2; rapidly absorbed/eliminated; non-combustible; cheap; widely available
What type of prep would you use for an emergent trauma ex lap and after prepping, how long do you need to wait to drape
betadine, immediately drape
Renal effects (renal blood flow)
decreased renal blood flow
Leak at skin where port enters cavity.
apply penetrating towel clamp or suture around port or use of a balloon-tipped trocar.
what lab findings can cause pseudohyponatremia
Pseudohyponatremia: Clinicians must exclude this laboratory artifact, which is typically caused by severe hyperlipidemia or hyperproteinemia.
Hyperglycemia Dilution: High glucose draws water extracellularly, diluting measured sodium. This must always be corrected to evaluate true status.
How does obesity affect abdominal wall compliance and required insufflation pressures?
Decreased abdominal wall compliance with increasing BMI → higher insufflation pressures needed
How long after initial surgery does delayed presentation of bowel injury 2/2 energy device injury occur?
Typically manifests 3 to 7 days post-op with free air or fluid, progressing rapidly to localized necrosis, perforation, and potential SIRS.
Pulmonary effects (minute ventilation, peak airway pressure, FRC)
increased minute ventilation, increased peak airway pressure, decreased FRC
If measured pressure is low and flow is absent
indicates power may not be on or CO2 gas may be low
Your patient's AM labs come back with hyperkalemia to 5.8 - what do you do?
- Insulin/dextrose
- Obtain EKG
- Administer IV Calcium Gluconate immediately to protect the cardiac membrane before attempting to shift or eliminate potassium.
What are the ways to confirm successful Veress needle entry (4)
Audible ”click” as each layer of the abdominal wall is traversed.
Tactile loss of resistance with insertion, freely mobile tip, no blood or enteric contents on aspiration, and free flow of saline through the needle
Low insufflation pressure (≤ 8 mm Hg) with low-medium flow.
Tympany during abdominal percussion after insufflation
Order the following skin preparations in order from lowest percent isopropyl alcohol to highest:
DuraPrep, betadine, chloraprep, hibiclens
betadine < hibiclens < chloraprep < duraprep
Cardiovascular effects (CO, preload, afterload)
decreased CO, decreased preload, increased afterload)
If measured pressure is low and flow is high
→ indicates a leak in the insufflation circuit
· Check that insufflator tubing is connected
· Check that all port valves are closed
· Check for leaking CO2 from port sites
· Check for distention of bowel or foley catheter bag (indicating bowel/bladder injury)
replacement of magnesium
Describe the Hasson Open Technique
-Incision & Dissection: Make a 10–12 mm vertical or transverse skin incision (usually at the umbilicus). Use blunt dissection to separate subcutaneous fat until the linea alba (fascia) is clearly exposed.
- Grasping & Incising Fascia: Grasp the fascia with Kocher clamps. Make a vertical full-thickness incision through the fascia.
- Placing Stay Sutures: Place stay sutures on both edges of the fascial incision.
- Entering the Peritoneum: Tent up the preperitoneal fat and peritoneum using clamps, then sharply dissect through the peritoneum to enter the abdominal cavity.
- Digital Sweep: Insert a finger into the opening to sweep the underside of the abdominal wall. This confirms entry into the peritoneal cavity and frees up any adhesions.
- Trocar Insertion: Insert the blunt-tip Hasson trocar into the cavity. Secure it to the abdominal wall by tying the previously placed stay sutures around the anchor on the trocar.
- Insufflation: Connect the CO₂ insufflation tubing to the port to inflate the abdomen
Describe antenna coupling, capacitive coupling, and direct coupling
antenna coupling - Energy transfers to non-electrified monitoring wires and may burn attachment sites.
capacitive coupling - Energy transfers to nearby cables, such as camera cords, and can induce burns.
direct coupling - An energized device transfers current to another instrument.
Management of gas embolism (4 steps)
- Evacuate the pneumoperitoneum
- position the patient in the steep Trendelenburg, left lateral decubitus position
- provide aggressive hydration and 100% oxygenation; resuscitate with vasopressors or inotropes as needed
- aspirate out the gas via a central venous catheter in the right internal jugular vein.
If measured pressure is >/= the preset pressure but flow is absent
1. wrong set pressure of pneumoperitoneum, 2. inadequate muscle relaxation of patient, 3. incorrect valve connection in insufflator tubing, 4. Obstructed tubing (e.g. somebody standing on it)
Recommended rate of hyponatremia correction
Serum sodium must be corrected by strictly less than 10 to 12 mEq/L in the first 24 hours, and strictly less than 18 mEq/L within the first 48 hours.