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NEPHRECTOMY ​ ​ A nephrectomy is a surgical procedure to remove all or part of a kidney: ​ Types of Nephrectomy: Radical Nephrectomy: Removal of the entire kidney, along with a portion of the tube leading to the bladder (ureter), the adrenal gland, and some surrounding fatty tissue. Simple Nephrectomy: Removal of just the kidney. Partial Nephrectomy: Removal of only the diseased or injured portion of the kidney. It's also called kidney-sparing or nephron-sparing surgery. Reasons for Nephrectomy: Kidney cancer or tumor A non-functioning or damaged kidney due to infection, scarring, or other disease. Severe injury to the kidney. Donor nephrectomy, where a kidney is removed for transplantation. Surgical Approaches: Open Nephrectomy: A large incision is made in the abdomen or side to access the kidney. This approach is less common these days but may be used for particularly large tumors or in complex cases. Laparoscopic Nephrectomy: Small incisions are made, and long instruments are used to remove the kidney. A small camera (laparoscope) guides the surgeon. This approach usually results in shorter recovery time and less pain than open surgery. Robotic-Assisted Laparoscopic Nephrectomy: Similar to laparoscopic but performed using a robotic system. The surgeon controls robotic arms from a console. Benefits of laparoscopic approach include less pain, earlier PO intake, and shorter hospitalization. ​ Renal cell carcinoma is most prevalent in males over 50 years old. ​ Anesthetic Implications for Nephrectomy ​ Anesthesia type: General ​ Airway: ETT ​​ Preoperative: ​ ​ For renal cell carcinoma, patients undergo preop staging to determine if the tumor involves the IVC or right atrium Tumor can obstruct IVC and reduce venous return (causes hypotension) Patients with cavo-atrial involvement will need anticoagulation with heparin therapy Preoperative arterial embolization of the kidney can facilitate surgery IVC may need to be clamped during resection Patient may be anemic An arterial line is standard, and a central line may be needed Two large-bore peripheral IVs Potential for significant blood loss ​ Intraoperative: ​ ​ Supine position for transabdominal approach Flexed lateral decubitus position for retroperitoneal approach Duration based on surgeon experience Expected EBL 200-500 (significantly higher for tumors involving renal vessels or IVC) Mannitol and/or furosemide may be administered for maintenance of urinary output Preserve renal blood flow with adequate hydration Pneumoperitoneum decreases renal blood flow Avoid nephrotoxic drugs, hypotension, and hypovolemia During flank incision, the pleura space may be accidentally entered through a diaphragm tear (requires chest tube) Thoracoabdominal incision usually requires chest tube at the end of surgery ​ Postoperative: ​ If significant extension into IVC, patient may require cardiopulmonary bypass Those with cavo-atrial disease should be cared in a critical care unit Pain management ​ Complications: ​ Pneumothorax Diaphragmatic injury Pulmonary embolus Arrhythmias Renal failure and need for dialysis Bleeding Respiratory complications Damage to surrounding structures (hollow viscus injuries and splenic lacerations) Urinary leak Hemodynamic instability Bowel obstruction Peritonitis Wound infection ​ ​ S ources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Kentucky Department of Anesthesiology Anesthesia Renal Keyword Review Cleveland Clinic Robotic Radical Left Nephrectomy with IVC Level III Thrombectomy GIBLIB Nephrectomy, Adrenalectomy & Retroperitoneal Lymphadenectomy

ABDOMINAL AORTIC ANEURYSM (AAA) REPAIR ​ Open abdominal aortic aneurysm (AAA) repair is a surgical procedure performed to treat an abdominal aortic aneurysm. An abdominal aortic aneurysm is a bulge or dilation in the aorta, the largest artery in the body, which runs through the abdomen. If left untreated, an AAA can rupture, leading to life-threatening internal bleeding and potential death ​ The open AAA repair procedure involves the following steps: ​ Anesthesia: The patient is administered general anesthesia, rendering them unconscious and unable to feel pain during the surgery. Incision: The surgeon makes a long incision in the abdomen, usually along the midline, to access the aorta. Exposure of the aorta: The surgeon carefully exposes the aorta and the aneurysm, temporarily clamping the blood flow above and below the aneurysm to prevent excessive bleeding. Removal of the damaged aortic segment: The surgeon opens the aneurysm sac and removes any blood clots or debris. They then carefully remove the damaged section of the aortic wall. Graft placement: A synthetic tube-like graft, made from materials like Dacron or polytetrafluoroethylene (PTFE), is sewn in place to replace the removed section of the aorta. The graft is designed to be durable and resistant to infection. Reestablishing blood flow: The surgeon releases the clamps above and below the graft, restoring blood flow through the aorta and checking for any leaks around the graft. Closure: Once the graft is securely in place and blood flow is normal, the surgeon closes the aneurysm sac around the graft, if possible, and sutures the abdominal incision. Open AAA repair has been the gold standard for treating abdominal aortic aneurysms for many years. However, in recent years, endovascular aneurysm repair (EVAR) has become a popular alternative, as it is less invasive and has a shorter recovery time. The choice between open AAA repair and EVAR depends on factors such as the patient's overall health, anatomy, and the size and location of the aneurysm. The surgeon will evaluate these factors and determine the most appropriate treatment approach for each patient. ​ ​ Anesthetic Implications for AAA ​ Anesthesia type: General ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Identify high-risk patients for preoperative optimization Risk factors of abdominal aortic aneurysm (AAA): increasing age, male gender, smoking, elevated plasma cholesterol levels, hypertension, and family history Patients may have COPD and history of smoking Patients are vasculopathic Coronary artery disease (CAD) is present in 30–40% of patients with AAA. Assume patients have disease of cerebral, cardiac, renal, and peripheral vasculature Smoking is the greatest risk factor Surgical repair of a AAA is recommended once the aneurysm expands to more than 5 cm Large bore venous access and arterial line should be placed Consider central venous access for longer procedures 5-lead electrocardiogram (monitor for ST changes) Evoked potentials monitoring may be requested for high-risk of spinal cord ischemia (SCI) patients Have access to rapid infusion devices Have IV fluid warmers and blood transfusion tubing available Patients are commonly on antiplatelet medications Bladder catheterization is indicated to monitor urine output The abdominal aorta begins in the diaphragm at T12 and ends at L4 The hallmark presentation for ruptured AAA Is severe back or abdominal pain ​ Intraoperative: ​ Ensure a smooth induction and cardiovascular stability Hypertension and tachycardia should be avoided on induction Type and screen and blood available in room Maintain blood pressure within 20% of the baseline Bradycardia is better than tachycardia 5 lead EKG with ST segment analysis Large bore IV and arterial line are placed May use of cell-saver technology. Have rapid infuser capability available When hemostasis is achieved the cross-clamps are released. Spinal cord perfusion in the thoracolumbar area is derived from the artery of Adamkiewicz Position: supine (midline abdominal incision) or lateral decubitus (retroperitoneal exposure) Prior to the cross-clamp is applied, heparin 100 units/kg IV is administered at the surgeon's request Heparinization and activated clotting time (ACT) checks 3 min after heparin and every 30 min thereafter Expect wide fluctuations in systemic vascular resistance with aortic cross-clamping and unclamping Decrease MAP before cross-clamp application (SBP around 90 mm Hg) Once the proximal aorta is clamped, there is an increase in blood pressure, SVR (afterload) and impedance to aortic flow above the clamp. Decreased venous return (preload) Myocardial oxygen demand increases and myocardial dysfunction can occur Monitor for left ventricle failure and myocardial ischemia When cross-clamping is on, SBP is normally maintained at 140–160 mm Hg for organ perfusion Document the cross-clamp application time (start of ischemic time) Prior to the cross-clamp being removed, provide volume loading and have vasopressors available Clamp removal is associated with hypotension, metabolic washout, and acidosis (ETCO2 increases) Metabolites cause vasodilation and myocardial depression Mannitol may be administered to maintain urine output and decrease the production of thromboxane Document the cross-clamp removal time (end of ischemic time) The surgeon can reclamp the aorta if hypotension persists Minimizing renal impairment: adequate hydration, limiting contrast, avoidance of nephrotoxic drugs Muscle relaxation is indicated Traction on the intestines and aortic cross-clamping can be associated with mesenteric mast cell release histamine (decreased systemic vascular resistance (SVR), hypotension, tachycardia) Hypothermia can cause dysrhythmias, depress cardiac contractility, and worsen coagulopathy Duration 3-5 hours EBL 500 ml ​ ​ Postoperative: ​ Smooth emergence Maintain hemodynamic stability Prevent hypertension and tachycardia on emergence Avoid coughing and bucking on emergence Assure full reversal of neuromuscular blockers Assess distal extremity circulation Epidural catheter for postop analgesia may be placed ​​ ​ Complications: ​ Death related to elective AAA repair commonly occurs from myocardial infarction Paraplegia Hemmorhage Mesenteric and bowel ischemia Myocardial infarction Renal ischemia and failure (from suprarenal or infrarenal aortic cross-clamping) Hepatic ischemia with coagulopathy Stroke Coagulopathy Hypothermia Respiratory failure Postoperative atelectasis Pneumonia ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia . ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Zero To Finals Understanding Abdominal Aortic Aneurysms Preop.com Abdominal Aortic Aneurysm Houston Methodist Hospital AAA Repair

VITRECTOMY A vitrectomy is a surgical procedure that involves the removal of the vitreous gel (or vitreous humor) from the eye. This procedure is often necessary for a variety of eye conditions and problems. The vitreous is a clear, gel-like substance that fills the space between the lens and the retina in the eye. Here are some key points about vitrectomy: ​ Indications for Surgery: Vitrectomy is commonly performed for conditions like retinal detachment, macular hole, epiretinal membrane, vitreous hemorrhage, and complications related to diabetic retinopathy. It may also be necessary in cases of severe eye trauma or to remove foreign bodies from the eye. Procedure: The surgery is typically done under local or general anesthesia. The surgeon makes small incisions in the sclera (the white part of the eye) and inserts specialized instruments. The vitreous gel is removed and often replaced with a saline solution, gas bubble, or silicone oil to help maintain the shape of the eye and support the retina. Recovery: Post-operative recovery can vary depending on the specific condition being treated and the complexity of the surgery. The patient may need to maintain a specific head position for several days, especially if a gas bubble is used. This positioning helps the retina to heal properly. It's common to experience some discomfort and vision changes as the eye heals. Anesthetic Implications for Vitrectomy ​ Anesthesia type: General, Sedation with local anesthesia (retrobulbar block) ​ Airway: ETT or LMA , natural airway ​​ Preoperative: ​ ​ Patients may have diabetes and hypertension The vitreous humor makes up two-thirds of the volume of the eye “Floaters” are deposits in the normally clear vitreous fluid This procedure is performed through a microscope Several tiny incisions are made on the sclera Do not use nitrous oxide ​​ Intraoperative: ​ Position: supine, slight reverse Trendelenburg, turned 90-180 degrees Duration: 30-90 minutes Monitor for bradycardia and the oculocardiac reflex ​ Postoperative: ​ An eye patch and shield are placed over the operative eye at the end PONV prophylaxis Smooth emergence without coughing or bucking ​​ Complications: ​ Corneal edema Retinal detachment Increased intraocular pressure Infection Intraocular hemorrhage ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Eye Surgery Ltd Vitrectomy Surgery Wills Eye Hospital Pars Plana Vitrectomy for Vitreous Floaters American Academy of Ophthalmology Eye Anatomy

BUNIONECTOMY ​ A bunionectomy is a surgical procedure performed to correct a bunion, which is a bony bump that forms at the base of the big toe joint. Bunions can cause pain, inflammation, and difficulty walking, and they may also lead to other foot problems if left untreated. A bunionectomy aims to alleviate these symptoms by removing the bunion and realigning the affected toe. ​ There are several different types of bunionectomy procedures, and the choice of procedure depends on the severity of the bunion and the patient's individual needs. Some common types of bunionectomy include: ​ Osteotomy: In this procedure, the surgeon makes a cut in the bone near the big toe joint to realign it. The bone may be held in place with screws, pins, or plates. Exostectomy: This procedure involves removing the bony bump (exostosis) without correcting the underlying bone deformity. It is usually performed in conjunction with other procedures to realign the toe. Lapidus procedure: In this technique, the surgeon fuses the joint at the base of the big toe to correct instability in the foot that may contribute to the bunion. Distal soft tissue realignment: This procedure involves adjusting the soft tissues around the big toe joint to help realign the toe. Resection arthroplasty: This is a more aggressive procedure, in which the surgeon removes a portion of the joint to alleviate pain and deformity. This is typically reserved for severe cases or elderly patients with limited mobility. ​ The recovery period for a bunionectomy varies depending on the type of surgery performed and individual factors. It generally involves a period of rest, elevation, and immobilization of the foot, followed by gradual reintroduction of weight-bearing activities and physical therapy. Full recovery can take several weeks to months, depending on the specific procedure and individual healing process. ​ Anesthetic Implications for Bunionectomy ​ Anesthesia type: G eneral anesthesia, regional anesthesia (spinal, epidural, or peripheral nerve block), or monitored anesthesia care with local anesthesia ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Determine the most suitable anesthesia technique ​ Intraoperative: ​ A compression tourniquet may be used The tourniquet should be released after 2 hours to prevent injury Supine position with arms out Duration: 30 to 60 minutes EBL minimal ​ Postoperative: ​ Pain management ​ Complications: ​ Foot deformity Chronic pain ​ Sources: ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Health Decide Bunion and Bunionectomy SurgMedia Lapiplasty Bunion (Hallux Valgus) Foot and Ankle Associates Minimal Incision Lapiplasty

AXILLARY LYMPH NODE DISSECTION (ALND) Axillary node dissection is a surgical procedure performed to remove lymph nodes from the axillary (armpit) region of the body. This procedure is commonly carried out during breast cancer surgery, as the axillary lymph nodes are one of the first places breast cancer cells are likely to spread. The goal of axillary node dissection is to assess the extent of cancer spread and determine the appropriate course of treatment. There are two types of axillary node dissections: ​ Sentinel lymph node biopsy (SLNB): In this procedure, the surgeon removes only the sentinel lymph node(s), which are the first lymph node(s) that cancer cells would potentially spread to from the primary tumor. A dye or radioactive substance is injected into the area around the tumor, which helps identify the sentinel node(s). If the sentinel node(s) test negative for cancer cells, it's less likely that the cancer has spread to other lymph nodes. Axillary lymph node dissection (ALND): This procedure involves removing a larger number of lymph nodes (usually 10-40) from the axilla. ALND is typically performed when cancer cells are found in the sentinel lymph node(s) or when there is clinical suspicion of lymph node involvement. ​ Axillary lymph node dissection (ALND) has been largely replaced by the minimally invasive technique of sentinel lymph node biopsy (SLNB) for breast cancer staging. ​ The lymph nodes with the highest radioactive signals are removed. ​ Women with positive SLNB may require subsequent ALND and further treatment. ​ Following the surgery, the removed lymph nodes are examined by a pathologist to determine the extent of the cancer spread. This information, along with other factors such as tumor size and grade helps guide the decision on further treatments, such as chemotherapy, radiation, or hormone therapy. Anesthetic Implications for ALND ​ Anesthesia type: General anesthesia or local anesthesia + IV sedation ​ Airway: Endotracheal tube or LMA ​​ Preoperative: ​ ​ Patients are frequently very anxious due to the possibility of breast malignancy Avoid BP cuff or IV in the ipsilateral arm Monitor and prevent brachial plexus injuries caused by overstretching the arm Breast cancer is the most common cancer among women ​​ Intraoperative: ​ May need to avoid muscle relaxants Duration for SLNB: 10-30 minutes Duration of ALND: 1.5 hours ​Position: Supine, one arm extended, one arm tucked EBL: Minimal Isosulfan blue dye may cause an artifactual drop in O2 saturation Isosulfan dye reaction: Itching, localized swelling, blue hives, hypotension ​ Postoperative: ​ Pain management Monitoring for complications ​​ Complications: ​ ​Allergic dye or radioisotope reaction Discoloration of urine and stool Blue staining of the skin Anaphylaxis Nerve injury: Long thoracic nerve, thoracodorsal nerve, and intercostobrachial nerve Lymphedema ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Sherwin, A., & Buggy, D. J. Anaesthesia for breast surgery. Mater Misericordiae University Hospital and University College Dublin. Retrieved from https://www.bjaed.org/article/S2058-5349(18)30101-X/pdf ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Medical Tutorials 3D Animation of Axillary Lymph Node Dissection (1) Medical Tutorials 3D Animation of Axillary Lymph Node Dissection (2) Medical Tutorials 3D Animation of Axillary Lymph Node Dissection (3)

CESAREAN SECTION ​ A cesarean section , often referred to as a C-section, is a surgical procedure used to deliver a baby through an incision in the mother's abdomen and uterus. This procedure is usually performed when a vaginal delivery would put the baby or mother at risk. ​ Some reasons for a C-section can include: ​ Multiple births: If a mother is having twins, triplets, or more, a C-section might be the safest delivery option. Baby's health: If the baby has a known health concern or abnormality that could make a vaginal birth risky, a C-section may be recommended. Position of the baby: If the baby is breech (bottom or feet first) or transverse (sideways), a C-section is often necessary. Previous C-section: If a mother has had a previous C-section, especially if the incision was vertical, her doctor might recommend repeat C-sections for future births to reduce the risk of uterine rupture. Failure to progress: If labor is not progressing as it should, a C-section might be the best option. Placental issues: If there are problems with the placenta, such as placenta previa (when the placenta is so low in the uterus that it covers the cervix), a C-section might be required. Mother's health: Certain health conditions, such as HIV or active genital herpes, might make a C-section the safer way to deliver the baby. In addition, if the mother has a health problem like heart disease or high blood pressure, a C-section might be the safest option. Emergency C-section is commonly done for fetal distress/bradycardia, non-reassuring fetal heart tones (FHT), hemorrhage, uterine rupture, or a prolapsed umbilical cord. ​ After a C-section, women usually stay in the hospital for around three to four days before going home. Recovery from a C-section generally takes longer than from a vaginal birth. It's important for women to take it easy and get as much rest as possible to allow their bodies to heal. ​ Anesthetic Implications for Cesarean Section ​ Anesthesia type: Neuraxial block (Spinal or epidural). General anesthesia is appropriate if the neuraxial block is refused, contraindicated, ineffective, or in an emergency ​ Airway: ETT if general anesthesia ​​ Preoperative: ​ ​ Always be prepared to implement general anesthesia Aortocaval compression can occur in the supine position (decreased venous return, decreased cardiac output, and uteroplacental insufficiency can occur) All pregnant patients are considered “full stomach” GI prophylaxis against aspiration for the possibility of general anesthesia Fetal heart tones (FHT) are commonly assessed before and after neuraxial anesthesia is implemented Prior to the implementation of the neuraxial block, 500-1000 mL of fluid is usually infused due to hypotension from sympathectomy A sensory block up to T4-T6 segmental level is required The surgeon should check that mother is insensate via pinch test before making the initial incision The patient should be instructed she should not feel sharp pain, but will likely feel movement and pressure Pressure is commonly felt when applying manual pressure to deliver the fetal head and when the uterus is external to the abdominal cavity for suturing The pregnant patient has compensated respiratory alkalosis (increased minute ventilation, decreased functional residual capacity, increased oxygen consumption Smaller ETT is used for GETA due to mucosal capillary engorgement Avoid nasal airways Parturients have reduced time to desaturation during apnea The pregnant patient has decreased systemic vascular resistance (SVR), decreased diastolic pressure and MAP, and increased heart rate and cardiac output Iron deficiency anemia is normally superimposed on the dilutional anemia of pregnancy Parturients have increased intragastric pressure, decreased esophageal sphincter tone, and decreased gastric motility predisposing them to aspiration pneumonitis MAC of inhaled agents is decreased Sensitivity to local anesthetics is increased Contraindications to regional anesthesia include patient refusal, coagulopathy, active neurological disease, elevated intracranial pressure, and active infection at the site Rapid sequence induction with cricoid pressure for GETA ​ Intraoperative: ​ Position: Supine with the arms extended on armboards A wedge can be placed under the right hip for left uterine displacement If the patient complains of nausea, treat for hypotension and give antiemetic Ephedrine and phenylephrine (Neosynephrine) are the vasopressors commonly given After delivery, the uterus is brought out of the wound to be sutured. This step can cause a lot of pressure and pain for the mother After the baby is delivered: If the patient becomes anxious or complains of pain, it is ok to give benzodiazepines or narcotics Pitocin (oxytocin) 20–40 units added to a 1 L bag of IV fluid and administered after delivery and separation from placenta Oxytocin is the first-line uterotonic drug to prevent and treat uterine atony and postpartum hemorrhage EBL +500 ml Duration: 1-2 hours Uterine massage is performed by nurse applying heavy pressure on the abdomen to stop uterine bleeding ​ Postoperative: ​ Tubal ligation may be performed at the time of cesarean section For boggy and bleeding uterus, Methergine IM or Hemabate IM can be administered per surgeon request if GETA, the patient should be extubated fully awake and fully reversed Multimodal analgesia should be utilized Patient-controlled analgesia (PCA) ​ Complications: ​ Amniotic fluid embolism Venous thromboembolism (VTE) Postpartum hemorrhage (PPH) ​ Sources: ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Dr.G Bhanu Prakash Cesarean Delivery Armando Hasudungan Physiological Changes During Pregnancy University of Kentucky Physiology of Pregnancy

MYRINGOTOMY AND TYMPANOSTOMY ​ ​ Myringotomy is a surgical procedure that involves making a small incision in the eardrum (the tympanic membrane) to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear. This procedure can be necessary in cases of chronic or recurrent middle ear infections or in patients with eustachian tube dysfunction, which can lead to problems with hearing or persistent discomfort. ​ A myringotomy may be performed in conjunction with the placement of a tympanostomy tube (also known as an ear tube) into the incision. This tiny tube helps to maintain aeration of the middle ear and allows for continued drainage of fluid, thereby helping to prevent future ear infections and related issues. ​ The procedure is typically done under general anesthesia in children and can be performed under local anesthesia in adults. It's usually quick, taking only about 15 to 30 minutes, and the recovery period is relatively short. Following the procedure, patients might experience mild discomfort or minor changes in hearing, but these typically resolve within a short time. ​ A myringotomy is often a very effective treatment for chronic ear infections and eustachian tube dysfunction, offering relief from symptoms and helping to prevent potential complications, such as hearing loss. It is typically recommended after more conservative treatment measures, such as antibiotics or nasal steroids, have failed to resolve the issue. ​ Anesthetic Implications for Myringotomy ​ Anesthesia type: General ​ Airway: Mask, LMA, or ETT ​​ Preoperative: ​ ​ Myringotomy is a commonly performed procedure in pediatrics Assess for upper respiratory infection Mask induction with sevoflurane +/- N2O in pediatrics An oral airway is usually inserted to facilitate bag-mask ventilation or spontaneous ventilation In tympanostomy, ear tubes are placed Antibiotic ear drops are usually instilled after placing the tubes ​ Intraoperative: ​ ​ Position: Supine with head turned away from the surgical site Duration 5-10 minutes Keep the child covered and warm ​ Postoperative: ​ Pain management PONV prophylaxis Monitor for emergence delirium ​ Complications: ​ Infection Perforation of the eardrum Scarring Laryngospasm PONV Emergence delirium ​ ​ ​ ​ ​ ​ S ources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Nucleus Medical Media Myringotomy for Ear Infection Otology in Paris Myringotomy, Ventilation Tube Insertion Gene Liu, MD MMM FACS Ear Tube Surgery (actual video)

TRANSURETHRAL RESECTION OF BLADDER TUMOR (TURBT) Transurethral Resection of Bladder Tumor (TURBT) is a common surgical procedure used in the diagnosis and treatment of bladder cancer. This procedure involves the removal of bladder tumors through the urethra, avoiding the need for an external incision. ​ Here are key aspects of TURBT: Purpose: TURBT is primarily used to diagnose bladder cancer and determine its stage and grade. It can also serve as a treatment for early-stage bladder cancer. Procedure: The surgeon inserts a cystoscope (a thin tube with a camera and light) through the urethra into the bladder. Special instruments are then used to remove the tumor or tumors from the bladder wall. This is usually done under general or spinal anesthesia. Diagnostic Role: Tissue samples obtained during TURBT are sent to a laboratory for analysis. This helps in determining the type of bladder cancer, its aggressiveness, and how far it has penetrated the bladder wall. ​ ​ Anesthetic Implications for Transurethral Resection of Bladder Tumor (TURBT) ​ Anesthesia type: General, neuraxial ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Patients are usually elderly often with multiple comorbidities Neuraxial anesthesia needs to be at the T10 level ( blocks the pain from bladder distention by the irrigating fluid) ​​ Intraoperative: ​ Position: lithotomy Duration: 1-2 hours Movement can cause injury or perforation Absorption of a large volume of fluid can result in signs of “water intoxication” TURP Syndrome: “water intoxication” with hypervolemia and dilutional hyponatremia TURP Syndrome: seizures, arrhythmias, bradycardia (vagal response), and unexplained hypotension or hypertension The time of transurethral resection should not exceed 2 h because excessive absorption of the irrigating fluid The obturator nerve is a mixed nerve with motor and sensory fibers. It arises from the anterior primary rami of L2, L3 and L4 in the lumbar plexus Reducing the diathermy current used during resection reduces the risk of obturator jerk Anesthetists should factor in the obturator jerk when considering the most appropriate anesthetic technique and should consider the use of neuromuscular blockade to reduce the risk of bladder perforation ​ Postoperative: ​ Pain management ​​ Complications: ​ Bleeding ​ Bladder perforation TURP Syndrome: volume overload, cerebral edema, hemolysis, hemoglobinuria, and hyponatremia Urinary Incontinence (injury to external sphincter) Erectile Dysfunction Retrograde Ejaculation Urethral Stricture Postoperative septicemia Aspiration Hypothermia Myocardial ischemia DVT Postoperative cognitive impairment Acute renal failure Pulmonary edema ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Panagoda PI, Vasdev N, Gowrie-Mohan S. Avoiding the Obturator Jerk during TURBT. Curr Urol. 2018 Oct;12(1):1-5. doi: 10.1159/000447223. Epub 2018 Jun 30. PMID: 30374273; PMCID: PMC6198773. ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips United Urology TURBT for Bladder Cancer European Association of Urology TURBT for Bladder Cancer University of Kentucky Anesthesia Renal Keyword Review

PORTACATH/MEDIPORT INSERTION ​ A portacath, or port-a-cath , is a medical device that's implanted under the skin to allow easy access to the bloodstream, typically used for patients who need frequent or long-term intravenous therapy, like chemotherapy. The procedure involves two main components: Catheter: A thin, soft, flexible tube. Port: A small reservoir or chamber that sits under the skin, usually in the upper chest. ​ Procedure for Insertion: Preparation: The patient is typically given a local anesthetic and sometimes sedation. The area where the port will be inserted is cleaned and prepared. Making an Incision: A small incision is made on the skin, often on the upper chest. Inserting the Catheter: The catheter is threaded into a large vein, often the superior vena cava, near the heart. Placing the Port: The other end of the catheter is connected to the port, which is then placed under the skin. Securing and Closing: The port is secured in place, and the incision is closed with sutures or surgical glue. ​ Advantages: Reduces the need for repeated needle sticks. Can stay in place for long periods, sometimes years. Used for various treatments, including chemotherapy, blood transfusions, and antibiotic therapy. ​ Anesthetic Implications for Portcath/Mediport Insertion ​ Anesthesia type: General, TIVA, MAC, sedation, local ​ Airway: ETT, LMA, spontaneous ventilation ​​ Preoperative: ​ Used in chronically ill patients The implantable access ports are associated with improved patient comfort and reduced infection rates Surgeon will be at the head of the bed X-ray will be used to check placement The surgeon will inject numbing medication in the area of the incision ​ Intraoperative: ​ ​ Position: supine, slight trendelenburg Duration: 30-90 minutes Slight trendelenburg position improves vein engorgement and prevents air entrapment into the intravascular space ​ Postoperative: ​ Assess for complications ​ Complications: ​ Bleeding/hematoma Infection Pneumothorax Vascular injury Arterial puncture Venous air embolus Thrombus Arrhythmias ​ ​ S ources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ Vacanti, C., Segal, S., Sikka, P., & Urman, R. (Eds.). (2011). Essential Clinical Anesthesia (1st ed.) ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Sarel Gaur MD How to place a Portacath (Mediport Insertion) Hope For Stomach Cancer Principles of Port A Cath Placement & Management Kenhub - Learn Human Anatomy Veins of the thorax

PERCUTANEOUS NEPHROLITHOTOMY (PCNL) ​ ​ Percutaneous Nephrolithotomy (PCNL) i s a surgical procedure used to remove kidney stones. In this procedure, a small incision is made in the patient's back, and a nephroscope (a special type of endoscope) is inserted directly into the kidney. The kidney stones are then either extracted or broken down into smaller pieces using laser or ultrasonic devices. This method is typically used for larger stones or when other treatments like extracorporeal shock wave lithotripsy (ESWL) are not effective. ​ " Percutaneous" means through the skin ​ Nephrolithotomy: nephro- (kidney), litho-(stone), and -tomy (removal) ​ Nephrolithotripsy: nephro- (kidney), litho (stone), and -tripsy (crushed) ​ Anesthetic Implications for Percutaneous Nephrolithotomy (PCNL) ​ Anesthesia type: General ​ Airway: ETT ​​ Preoperative: ​ Elderly patients may have many comorbidities Patients may have hydronephrosis causing deranged renal functions and sepsis Avoid pressure on the eyeballs in the prone position Maintain cervical neutrality Fluoroscopy/xray considerations (lead aprons and thyroid shields) Paraplegics and quadriplegics have the risk of developing autonomic hyperreflexia ​ Intraoperative: ​ ​ Fiberoptic nephroscope is inserted into the kidney through a small flank incision Position: prone or lateral Duration: 1-2 hours ​ Postoperative: ​ Postoperative fevers may occur ​ Complications: ​ Injury to the pleura and lungs Pneumothorax Injury to major blood vessels Bleeding Hepatic or splenic injury Bowel injury Accidental extubation and kinking of endotracheal tube Facial and ocular edema when prone position Volume overload Electrolyte imbalances ​ ​ S ources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ Vacanti, C., Segal, S., Sikka, P., & Urman, R. (Eds.). (2011). Essential Clinical Anesthesia (1st ed.) ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Cleveland Clinic Percutaneous Nephrolithotomy Ninja Nerd Renal | Kidney Anatomy Model Kelina Hospital Percutaneous Nephrolithotomy (PCNL)

UMBILICAL HERNIA REPAIR Umbilical hernia repair is a surgical procedure used to fix umbilical hernias. An umbilical hernia occurs when part of the intestine or fatty tissue bulges through the abdominal muscles near the navel (belly button). This condition is common in infants, but it can also occur in adults, often due to repeated strain on the abdominal area. ​ The surgery typically involves: Anesthesia: The procedure is usually performed under general anesthesia, meaning the patient is asleep and pain-free during the operation. Incision: A small incision is made near the umbilicus (navel). Repairing the Hernia: The protruding tissue is placed back into the abdominal cavity, and the opening in the abdominal wall is closed with stitches. Sometimes, a mesh material is used to strengthen the area. Closing the Incision: The incision is then closed with sutures, staples, or surgical glue. ​ The goals of umbilical hernia repair are to relieve symptoms and to prevent complications like incarceration (trapping of the hernia) or strangulation (cutting off the blood supply to the herniated tissue), which can be life-threatening. ​ The recovery time can vary depending on the patient's overall health, the size of the hernia, and the specific details of the surgery. Most people can return to normal activities within a few weeks, but complete healing might take longer. Anesthetic Implications for Umbilical H ernia Repair ​ Anesthesia type: General ​ Airway: ETT ​​ Preoperative: ​ ​ ​ The procedure can be performed as open or laparoscopic approach The patient’s peritoneum is insufflated Paralytics are used Pneumoperitoneum effects: decreased in functional residual capacity (FRC), increased systemic vascular resistance (SVR), decreased venous return, decreased renal blood flow, increased risk of regurgitation and aspiration of gastric content ​​ Intraoperative: ​ Position: supine position with at least one arm tucked Traction on the viscera can cause vagal stimulation and bradycardia Mesh is used to help close and supplement large umbilical hernias ​ Postoperative: ​ PONV prophylaxis Pain management Avoid coughing and straining on emergence Abdominal binder is placed after surgery ​​ Complications: ​ Urinary retention Infection Hernia recurrence Nerve damage Hemorrhage Organ damage Subcutaneous emphysema from pneumoperitoneum Bowel obstruction Bladder injury Postoperative ileus seroma DVT ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips California Hernia Specialists: Open Umbilical Hernia Repair Dr. R. K. Mishra Laparoscopic Repair of Umbilical Hernia Forever Learning PHYSIOLOGIC CHANGES IN LAPAROSCOPIC SURGERY-

NISSEN FUNDOPLICATION ​ ​ Nissen fundoplication is a surgical procedure used to treat gastroesophageal reflux disease (GERD). In this surgery, the upper part of the stomach (the fundus) is wrapped around the lower end of the esophagus. This wrapping creates a new valve mechanism at the bottom of the esophagus, helping to prevent acid reflux, where stomach contents and acid flow back into the esophagus. ​ The procedure is named after Rudolf Nissen, the surgeon who first performed it. It's often considered when long-term use of medication isn't effective or desired, and in cases where there are complications of GERD like esophagitis, Barrett's esophagus, or esophageal strictures. ​ Nissen fundoplication helps to strengthen and reinforce the GE junction, ​ The Nissen fundoplication can be performed laparoscopically, which involves several small incisions in the abdomen, or through a traditional open surgery. The laparoscopic method generally has a quicker recovery time and less post-operative pain. ​ ​ ​ ​ Anesthetic Implications for Nissen Fundoplication ​ Anesthesia type: General ​ Airway: ETT ​​ Preoperative: ​ ​ The patient must undergo anatomic and physiologic esophageal evaluation such as esophagogastroduodenoscopy (EGD) and esophageal motility study It is unnecessary to prep the colon for laparoscopic Nissen fundoplication ​ Intraoperative: ​ ​ An esophageal dilator (bougie) is lubricated and passed transorally to provide a stent that the surgeon can use to tighten the gastric fundus The circumferential fundus creates the fundoplication or “wrap.” Position: Modified lithotomy and reverse Trendelenburg Duration: 2-3 hours EBL: minimal Adequate muscle relaxation Establishment of pneumoperitoneum A nasogastric or orogastric tube is often placed to assist in decompression of the stomach ​ ​ Postoperative: ​ PONV prohylaxis Prevention of retching and vomiting ​ Complications: ​ Perforation of the stomach or esophagus Pneumothorax Bleeding Gas-bloat syndrome (increase in swallowed air) Abdominal distention Nausea Dysphagia (difficulty swallowing) ​ ​ S ources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Fauquier ENT Nissen Fundoplication Animation with Actual Surgical Footage Drugs.com Fundoplication Fauquier ENT Nissen Fundoplication with Hiatal Hernia Repair