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WHIPPLE PROCEDURE (PANCREATICODUODENECTOMY) The Whipple procedure, also known as pancreaticoduodenectomy, is a complex surgical procedure most commonly used to treat pancreatic cancer. It involves the removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, and the bile duct. In some cases, a portion of the stomach may also be removed. This surgery is named after Allen Whipple, the American surgeon who first described the procedure in the 1930s. ​ The Whipple procedure is typically performed in cases where the cancer is confined to the head of the pancreas and has not spread extensively. The primary goal is to remove the cancerous tissue and prevent the spread of the disease. ​ The steps of the procedure generally include: ​ Removal of the head of the pancreas, duodenum, gallbladder, and bile duct. Reconnecting the remaining pancreas, bile duct, and stomach (if involved) to the small intestine to maintain digestive functioning. ​ This procedure is one of the most challenging abdominal operations, primarily due to the complexity of the anatomy in that area and the need for precise reconstruction after removal of the organs. ​ Patients who undergo the Whipple procedure require lifelong monitoring and care. This includes nutritional support, as the removal of part of the pancreas and other digestive organs can impact the ability to digest food. There's also a need for regular check-ups to monitor for any signs of cancer recurrence or complications arising from the surgery. Anesthetic Implications for Whipple Procedure (Pancreaticoduode nectomy) ​ Anesthesia type: General, epidural anesthesia ​ Airway: ETT ​​ Preoperative: ​ ​ Challenging and technically demanding major abdominal procedure (results in a number of pathophysiological alterations) Severe electrolyte disturbances may be present with pancreatitis Patients with acute pancreatitis are usually hypotensive and hypovolemic Patients may have large third-space fluid shifts An arterial line is placed, ± central line, ± CVP Patients can lose large amounts of blood Large-bore IV access and invasive monitoring are normally used for fluid replacement, hemodynamic monitoring, and frequent arterial blood sampling Consider epidural TAP block can be administered Assess for respiratory compromise (pleural effusion, atelectasis) Hypocalcemia is often present (decreases myocardial contractility, prolongs QT interval) Hypocalcemia from the release of pancreatic lipase (mental fat saponification) The presence of ileus or abdominal obstruction requires rapid sequence induction Electrolyte abnormalities are common Warm fluids ​​ Intraoperative: ​ Position: supine, bilateral arms are tucked Expect prolonged operative time (4-7 hours) EBL 200-1000 mL Aggressive volume resuscitation may be required during surgery (crystalloids, colloids, blood products) ​ Postoperative: ​ Epidural may be placed for postoperative pain control Assess for hemodynamic and homeostatic stability Patients may need to be kept intubated due to large fluid shifts and compromised airway due to edema Nasogastric tube for postop Intensive respiratory rehabilitation ​​ Complications: ​ Significant fluid loss Bleeding Hypothermia Delayed gastric emptying Pulmonary complications (pneumonia) Pancreatic fistula Sepsis Myocardial infarction Biliary fistula Pulmonary aspiration Electrolyte imbalance Bowel leakage from anastomosis VTE PONV Hyperglycemia Pancreatogenic diabetes ​ ​ Sources: ​ De Pietri L, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol. 2014 Mar 7;20(9):2304-20. doi: 10.3748/wjg.v20.i9.2304. PMID: 24605028; PMCID: PMC3942834 ​ 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 Edusurg Clinics Whipple Procedure I Pancreaticoduodenectomy Mayo Clinic What is the Whipple Procedure Medical College of Wisconsin Pancreatic Anatomy and Whipple Operation

CERVICAL CERCLAGE (CERVICAL LIGATURE) ​ Cervical cerclage is a surgical procedure performed during pregnancy to help prevent preterm birth or miscarriage in women with a weak or short cervix. The cervix is the lower part of the uterus that opens into the vagina, and it plays a crucial role in maintaining the pregnancy by staying closed and firm until it's time for labor and delivery. ​ In a cervical cerclage, a stitch (suture) or synthetic tape is placed around the cervix to help strengthen and support it, thus reducing the risk of premature dilation or effacement (thinning). The procedure is usually performed between 14 and 24 weeks of pregnancy. ​ There are different techniques used for cervical cerclage, including: McDonald cerclage: A stitch is placed around the cervix, creating a purse-string effect to keep it closed. Shirodkar cerclage: A more advanced technique where the stitch is placed higher up in the cervix, requiring a small incision to access the area. In rare cases, an abdominal approach may be used. ​ Cervical cerclage is not appropriate for all women with a history of preterm birth or miscarriage. It is generally only recommended for women with a diagnosed incompetent cervix or a history of cervical insufficiency. The procedure does carry some risks, such as infection, bleeding, or rupture of membranes. ​ The cerclage is usually removed around 36-37 weeks of gestation to allow for natural labor and delivery, or earlier if labor starts prematurely or if complications arise. ​ The goal is to prevent cervical dilatation that might result in spontaneous abortion. ​ Anesthetic Implications for Cervical Cerclage ​ Anesthesia type: General, neuraxial (spinal or epidural), sedation/MAC with local anesthetic ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ If > 16-18 weeks, aspiration pneumonitis precautions and rapid sequence induction is indicated Drug exposure during organogenesis (15–56 d) should be minimized Use left uterine displacement after 20-week gestation due to aortocaval compression risk Maternal hyperventilation can reduce uteroplacental and umbilical blood flow +/- fetal heart rate monitoring Avoid midazolam and nitrous oxide The timing of cerclage during pregnancy determines the extent of physiologic changes ​ T10 to L1 and S2 to S4 sensory blockade is desired to provide coverage of the cervix, vagina, and perineum ​ Intraoperative: ​ Ensure adequate uteroplacental perfusion and fetal oxygenation Maintain normal maternal blood pressure and oxyhemoglobin saturation Volatile anesthetics can decrease uterine smooth muscle tone and decrease intrauterine pressure Position: Lithotomy, left lateral pelvic tilt; Trendelenburg Duration: 30 min to 1 hour EBL 25-50 mL ​ Postoperative: ​ PONV prophylaxis Pain management Avoid administration of NSAIDs during pregnancy due to the potential fetal effects ​ Complications: ​ Cervical trauma Preterm labor Spontaneous abortion Bleeding Rupture of membranes Chorioamnionitis Peroneal nerve compression from lithotomy position Hypotension ​ 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 AAUN Obs and Gynae Cervical Cerclage , RCOG Guideline SurgMedia Cervical Cerclage: McDonald Procedure University of Kentucky Obstetric Anesthesia: Keyword Review

HEMORRHOIDECTOMY ​ A hemorrhoidectomy is a surgical procedure used to remove hemorrhoids. Hemorrhoids are swollen blood vessels in or around the anus and rectum. While there are various non-surgical treatments that can be effective for managing hemorrhoids, a hemorrhoidectomy is typically reserved for severe or recurring cases that haven't responded to other treatments. Anesthetic Implications for Hemorrhoidectomy ​ Anesthesia type: General, TIVA, MAC, regional, local anesthesia ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ Check with the team regarding patient position such as lithotomy or prone jack-knife​ If prone, need prone view device and protection of face and eyes If prone without an advanced airway, have oral and nasal airways readily available The rectoperineal area is very sensitive Pain is common Surgeons normally request to limit IV fluids (500 cc IV bag with micro drip tubing) ​ Intraoperative: ​ Duration: 30-60 minutes Position: Supine, lithotomy, or prone ​ Postoperative: ​ Pain management ​ Complications: ​ Urinary retention Incontinence Bleeding Stricture Infection Peripheral nerve injury from positioning ​ 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 Nucleus Medical Media Hemorrhoidectomy JJ Medicine Hemorrhoids Signs & Symptoms

MASTECTOMY ​ ​ A mastectomy is a surgical procedure to remove one or both breasts, either partially or completely. It is most commonly performed as a treatment for breast cancer or to prevent it in those at high risk. Here's an overview of the types of mastectomy and the reasons they may be performed: ​ Types of Mastectomy: ​ Total (or Simple) Mastectomy: This involves removing the entire breast, including the nipple, areola, and most of the overlying skin, but not the lymph nodes in the underarm area (axillary lymph nodes). Modified Radical Mastectomy: The entire breast is removed, along with some of the axillary lymph nodes. The pectoral muscles remain intact. Radical Mastectomy: This procedure removes the entire breast, axillary lymph nodes, and chest wall muscles under the breast. This surgery is rare and usually only done when the cancer has spread to the chest muscles. Partial Mastectomy: Also known as a segmental mastectomy, this procedure removes the cancer and a portion of surrounding breast tissue, leaving the rest of the breast intact. Lumpectomy: This is a breast-conserving surgery where only the tumor and a small margin of surrounding tissue are removed. Although this is not technically a mastectomy, it's a related procedure. Double Mastectomy: This refers to the removal of both breasts and may be done as a preventive measure for those with very high risk of breast cancer, such as carriers of BRCA1 or BRCA2 gene mutations. Skin-Sparing Mastectomy: Most of the skin over the breast is left intact, and only the breast tissue, nipple, and areola are removed. This can make reconstruction easier. Nipple-Sparing Mastectomy: All the breast tissue is removed, but the nipple and areola are left intact. This may not be suitable for cancers close to the nipple. ​ Reasons for Mastectomy: ​ Treatment for Breast Cancer: If a person has been diagnosed with breast cancer, a mastectomy may be recommended, especially if the tumor is large or if there are multiple tumors in different parts of the breast. Preventive Measure: For individuals at high risk of developing breast cancer, such as those with a strong family history or known genetic mutations like BRCA1 or BRCA2, a prophylactic or preventive mastectomy may be considered. Recurrent Breast Cancer: If breast cancer returns after treatment, a mastectomy may be recommended. ​ Recovery: Recovery from a mastectomy can take several weeks, and physical therapy may be needed to regain arm movement. The emotional impact can also be significant, and counseling or support groups may be beneficial. ​ Reconstruction: ​ Breast reconstruction surgery can be performed at the same time as a mastectomy or later on. It can help restore the appearance of the breast, though sensation and the natural look and feel of the breast may not be fully restored. ​ Mastectomy is a major decision, and discussions with healthcare providers, including surgeons, oncologists, and genetic counselors, can help an individual make the choice that's best for them. ​ Anesthetic Implications for Mastectomy ​ Anesthesia type: General anesthesia ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ PIV in non-operative arm Blood pressure cuff in non-operative arm Chemotherapy agents (ex. anthracyclines) can cause cardiomyopathy Patients may have anemia or thrombocytopenia due to chemotherapy Consider EKG and echocardiogram Consider the utilization of nerve blocks and regional anesthesia When mastectomy and axillary dissection is scheduled, block T1-T6 is required Check with the surgeon regarding the use of paralytics because they interfere with nerve testing Breast implant procedure after the mastectomy will add a considerable amount of time to the case The BRCA gene has a known relationship with breast cancer The surgery may involve axillary lymph node exploration called "sentinel lymph node biopsy (SLNB)" The sentinel lymph node is the first axillary lymph node that would demonstrate metastatic disease ​ Intraoperative: ​ ​ Monitor the amount of local anesthetic used Position: supine, with the arm on the affected side extended Duration: 1-2 hours ​ Postoperative: ​ Smooth emergence from anesthesia Multimodal pain management PONV prophylaxis ​ Complications: ​ ​ Lymphedema Seroma Pneumothorax PONV Infection Hematoma Injury to neurovascular axillary structures ​ ​ ​ ​ 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 Brigham and Women's Hospital Mastectomy with Axillary Surgery Nucleus Medical Media Breast Cancer Surgery scanFOAM Regional Anesthesia for Breast Surgery

THYROIDECTOMY A thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. The thyroid gland is located in the neck and produces hormones that regulate the body's metabolism. Thyroidectomy is commonly performed for several reasons, including: ​ Thyroid Cancer: To remove cancerous thyroid tissue. Goiter: To remove a large thyroid gland that may be causing discomfort or breathing difficulties. Hyperthyroidism: To treat an overactive thyroid gland when other treatments are not suitable. ​ The procedure can be either a total thyroidectomy (removal of the entire gland) or partial (removal of part of the gland). The approach and extent of surgery depend on the reason for the surgery and the condition of the patient Anesthetic Implications for Thyroidectomy ​ Anesthesia type: General, local anesthesia ​ Airway: ETT, Neuromonitoring ETT, LMA ​​ Preoperative: ​ ​ Ideally, patients are clinically and chemically euthyroid prior to surgery Assess for airway compromise Assess goiter or nodule for size and extent of the lesion Large goiter can compress the airway or cause vocal cord paralysis Awake fibreoptic intubation may be used Be careful with preoperative sedation A Chest X-ray may be useful to assess the size of goitre and detect any tracheal compression or deviation Assess for signs of hyperthyroidism or hypothyroidism Check with the surgeon regarding muscle paralytics and nerve monitoring A NIM (Nerve Integrity Monitor) EMG endotracheal tube may be used (monitors manipulation of the recurrent laryngeal nerve) Muscle relaxants are not used if nerve monitoring is performed Hyperthyroid patients are frequently hypovolemic ​​ Intraoperative: ​ The thyroid gland is very vascular, May have to avoid paralytic due to recurrent laryngeal nerve monitoring Steroids (e.g. dexamethasone 8mg) may help to reduce airway edema Position: Supine, arms tucked, shoulder roll Duration: 1-2 hours ​ Postoperative: ​ Deep smooth extubation Avoid bucking/coughing Minimize airway manipulation High risk of PONV Postoperative calcium levels Hypocalcemia signs include stridor and laryngospasm Bilateral injury to the recurrent laryngeal nerves (RLN) can cause vocal cord paresis and stridor ​​ Complications: ​ Hypocalcemia Bleeding Pneumothorax Laryngeal edema Recurrent laryngeal nerve injury Superior laryngeal nerve injury Phrenic nerve injury Parathyroid glands injury Neck hematoma Airway compromise Thyroid storm Tracheomalacia Vascular injury Thoracic duct injury Tracheal injury Esophageal injury ​ ​ 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 Icahn School of Medicine Thyroidectomy University of Kentucky ENT Anesthesia University of Kentucky #2 ENT & Eyes

CAROTID ENDARTERECTOMY ​ Carotid endarterectomy is a surgical procedure performed to reduce the risk of stroke by removing plaque and fatty deposits from the carotid artery, which is one of the primary arteries supplying blood to the brain. This procedure is typically recommended for patients with significant carotid artery narrowing (stenosis) caused by atherosclerosis, which can lead to reduced blood flow to the brain and an increased risk of stroke. The surgery involves the following steps: ​ Anesthesia: The patient is given either general anesthesia, which puts them to sleep, or local anesthesia, which numbs the area around the carotid artery. Incision: The surgeon makes an incision along the front of the neck on the side where the blocked artery is located. Clamping: The surgeon clamps the carotid artery above and below the plaque-filled area to temporarily halt blood flow. Opening the artery: The surgeon makes a small incision in the artery to expose the plaque. Plaque removal: The surgeon carefully removes the plaque from the artery's inner lining. Repair: The surgeon stitches the artery back together, using a patch if needed to widen the artery and prevent narrowing. Unclamping: The clamps are removed, and blood flow is restored through the artery. Closing the incision: The surgeon closes the skin incision with sutures or staples. ​ After the surgery, patients may experience temporary neck pain, hoarseness, or difficulty swallowing. The recovery period varies depending on the patient's overall health, but most people can return to their normal activities within a few weeks. ​ Carotid endarterectomy is just one treatment option for carotid artery stenosis. In some cases, less invasive procedures, such as carotid angioplasty and stenting, may be considered. ​ ​ Anesthetic Implications for Carotid Endarterectomy ​ Anesthesia type: General, Regional ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Optimize the patient’s coexisting conditions Perform full neurological assessment Document neurologic deficits Careful use of benzodiazepines Placement of an arterial line Large bore IV x2 The Circle of Willis anatomy is normal in 50% of people Careful evaluation of the cardiovascular status If BP is different in the two arms, it should be measured in the arm with the highest values Normally elderly patients with CAD An awake patient is the most reliable method for assessing neurology ​ Intraoperative: ​ Maintain hemodynamic stability to ensure cerebral perfusion Minimize cardiac depression Cerebral protection by decreasing CMRO2 Patients may also experience large blood pressure swings (due to carotid sinus stimulation or loss of baroreceptors) Keep blood pressure higher to perfuse collateral areas Ischemic areas lose normal autoregulation and their functioning becomes pressure dependent Maintain normocapnia Cerebral monitoring can be done to assess cerebral perfusion EEG, somatosensory evoked potentials (SSEP), transcranial Doppler, and near infra-red spectroscopy (NIRS) The anesthetic choice should not interfere with any neurologic monitoring Heparinization prior to carotid artery clamping Heparin and protamine should be available Maintaining MAP 10–20% higher than baseline is recommended during carotid clamping Position: Supine, arms tucked, head slightly extended and tilted away from operative side Secure the ETT opposite from the operative side EBL 50-150 mL Duration 2-3 hours Total carotid occlusion time should be documented in the chart The arterial line transducer can be placed at the level of the head to assess cerebral perfusion pressure (CPP) Stump pressure may be transduced Stump pressure (pressure distal to clamp) evaluates the adequacy of cerebral perfusion Stump pressure is created by the backflow from the contralateral carotid artery across the circle of Willis Surgical stimulation to carotid receptors can cause bradycardia and hypotension Atropine and glycopyrrolate should be available Surgeon can apply lidocaine to carotid bulb to improve hemodynamic flunctuation A carotid shunt may be placed by surgeon The carotid shunt is a method used to bypass the carotid clamp and maintain ipsilateral perfusion during carotid cross-clamping Most anaesthetic agents reduce the cerebral metabolic rate ​ Postoperative: ​ Smooth and rapid emergence Maintain stable hemodynamics Avoid coughing and bucking Perform neurological examination Pain management ​ Complications: ​ Hyperperfusion syndrome Cerebral edema Postoperative hypertension Seizures Baroreceptor regulation loss Myocardial ischemia Postoperative stroke Hematoma formation Airway compression Vocal cord paralysis (recurrent laryngeal nerve damage) Cranial nerve injury Infection Loss of ipsilateral chemoreceptor carotid body function Tension pneumothorax ​ 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. ​ Zdrehuş C. Anaesthesia for carotid endarterectomy - general or loco-regional? Rom J Anaesth Intensive Care. 2015 Apr;22(1):17-24. PMID: 28913451; PMCID: PMC5505327. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Methodist Hospital Carotid Endarterectomy Leslie Schweitzer CEA Overview and Anesthetic Choices Mount Sinai Surgical Carotid Endarterectomy Calin Calabrese Vascular Anesthesia University of Kentucky Neurovascular Disease AltoseAnesthesia Neuro Anesthesia

COLECTOMY ​ A colectomy is a surgical procedure used to remove all or part of your colon. The colon, also known as the large intestine, is a long hollow tube at the end of the digestive tract where the body makes and stores stool. There are several types of colectomy operations: ​ Total colectomy: involves removing the entire colon. Partial colectomy: involves removing part of the colon and can be further categorized by the specific segment removed (left or right hemicolectomy, sigmoid colectomy). Hemicolectomy: involves removing the right or left portion of your colon. Proctocolectomy: involves removing both the colon and rectum. ​ A colectomy can be necessary to treat or prevent diseases and conditions that affect your colon, such as: Colon or rectal cancer Inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis Diverticulitis, a condition in which small, bulging pouches (diverticula) in the digestive tract become inflamed or infected Bowel obstruction Preventive surgery to remove precancerous polyps ​ The surgery can be performed in two ways, depending on your condition: Open colectomy: Your surgeon makes a long incision in your abdomen to remove part of the colon. Laparoscopic colectomy: Your surgeon performs the operation through several small incisions in the abdomen. ​ Colectomies are often done laparoscopically or robotically ​ After a colectomy, the surgeon attaches the remaining parts of the digestive system to allow waste to leave the body. This may involve creating an opening (stoma) on the outside of the body for waste to pass through, a procedure known as an ostomy. But this is often temporary and can be reversed later. ​ Anesthetic Implications for Colectomy ​ Anesthesia type: G eneral anesthesia. +/- epidural. Regional block ​ Airway: ETT ​​ Preoperative: ​ ​ The patient may have had a bowel prep and may be dehydrated Patients may have dehydration, electrolyte abnormalities, or anemia Patients with IBD may have inflammatory lung involvement Patients with IBD may have hepatic involvement and altered drug metabolism In case of bowel obstruction, RSI induction is advisable Full stomach precautions if acute abdomen Hemodynamic instability is more common in cases of sepsis and peritonitis Vomiting and gastric suctioning can cause metabolic alkalosis Hemoconcentration from dehydration may mask anemia in these patients Low albumin levels affect the free drugs in the blood GI malabsorption can impair coagulation system. Avoid nitrous oxide If there's a bowel obstruction and abdominal distension, it might limit the movement of the diaphragm. This can negatively influence the functional residual capacity (FRC) There's a risk of metabolic acidosis in patients who are experiencing diarrhea or undergoing bowel preparation Consider pre-hydration measures for hypovolemic patients ERAS protocol Consider preop acetaminophen/gabapentin /celecoxib ​ Intraoperative: ​ A nasogastric tube may be placed at the surgeon's request (for distention or vomiting) Muscle relaxants are administered Large fluid shifts are common (blood loss, third-spacing, insensible losses) Goal directed fluid therapy Manipulation of necrotic bowel or bowel rupture can cause hemodynamic instability Position: Supine with both arms tucked to sides. May need steep Trendelenburg, reverse Trendelenburg, or lithotomy EBL depends on pathology, complexity and patient factors ​ Postoperative: ​ Multimodal pain management Epidural anesthesia PONV prophylaxis May require ICU ​ Complications: ​ Small bowel obstruction (SBO) Anastomotic leak Splenic injury Injuries to bowel or ureters Infection Bleeding Wound dehiscence Sepsis Septic shock Aspiration of gastric contents Atelectasis VTE PONV ​ 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 Northwell Health Colectomy Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Colorectal Surgery University of Kentucky ERAS Anesthesia

TYMPANOSPLASTY Tympanoplasty is a surgical procedure used to repair a perforated tympanic membrane (eardrum) or to reconstruct the middle ear's hearing bones (ossicles). The primary goal of tympanoplasty is to improve hearing and prevent recurrent ear infections. There are several types of tympanoplasty, depending on the extent and location of the damage to the ear, and the specific techniques used can vary. ​ Here's a brief overview of the procedure and its types: Types of Tympanoplasty: Type I (Myringoplasty): Involves the repair of the tympanic membrane alone without touching the ossicles. Type II: Involves grafting onto the ossicles in addition to the tympanic membrane. Type III: The ossicular chain is rebuilt, and the graft is placed on the stapes (one of the ossicles). Type IV: A graft is placed on a mobile stapes footplate, and the rest of the ossicular chain is absent. Type V: Involves fenestration of the horizontal semicircular canal. Procedure: The procedure is often performed under general anesthesia. A surgeon will typically access the eardrum through the ear canal or via an incision behind the ear. Damaged parts are either removed or repaired, and a graft (often taken from the patient's own tissue) is used to patch the eardrum. Indications for Surgery: Chronic ear infections that don't respond to other treatments. Perforated eardrum, often from chronic infections or trauma. Hearing loss due to damage in the middle ear. ​ Anesthetic Implications for Tympanoplasty ​ Anesthesia type: General, local anesthesia ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Patients are generally young and healthy The function of the middle ear is to transmit sound from the environment to the inner ear The tympanic cavity is connected to the nasopharynx via the Eustachian tubes, which aerate the middle ear and equalize its pressure with that of the atmosphere Check with the surgeon before giving muscle relaxants (facial nerve monitoring) Need to identify and preserve the facial nerve The 7th cranial nerve goes through the temporal bone and originates in the brainstem EMG-based neural monitor is used to assess neural function ​​ Intraoperative: ​ Do NOT administer nitrous oxide ( change in air pressure in risks dislodgement of the graft) Facial nerve monitoring may be done Position: supine Controlled hypotension may be used to minimize blood loss and maintain clear surgical field ​ Postoperative: ​ Smooth emergence to prevent prosthesis displacement PONV prophylaxis Pain management ​​ Complications: ​ Bleeding Hematoma formation Facial nerve injury Suture line disruption Vascular injury Venous air embolism Transgression of the dura Spinal fluid leak PONV ​ ​ 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.). ​ Pairaudeau C, Mendonca C. Anaesthesia for major middle ear surgery. BJA Educ. 2019 May;19(5):136-143. doi: 10.1016/j.bjae.2019.01.006. Epub 2019 Mar 6. PMID: 33456882; PMCID: PMC7808081. ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Fauquier ENT Eardrum Hole Surgery - Transcanal Tympanoplasty Dr. Chushak Ruptured Eardrum Treatment Armando Hasudungan Anatomy - Ear Overview

LUMBAR LAMINECTOMY ​ ​ A lumbar laminectomy is a surgical procedure primarily designed to relieve pressure on the spinal cord or spinal nerves, often due to a condition called spinal stenosis. ​ Spinal stenosis involves a narrowing of the spinal canal, which can cause nerve compression that results in pain, numbness, or weakness, most commonly in the legs. In the lumbar region, this may also cause low back pain and difficulties in walking. ​ In a lumbar laminectomy, the surgeon removes the lamina, which is part of the vertebra that forms the "roof" of the spinal canal. Removing the lamina enlarges the spinal canal and reduces the pressure on the spinal cord or nerves. ​ Anesthetic Implications for Lumbar Laminectomy ​ Anesthesia type: General anesthesia ​ Airway: ETT ​​ Preoperative: ​ ​ Induction and intubation are performed while the patient is on the stretcher Additional lines should be placed before turning the patient over to the prone position Foam cradle or Prone View will be used for patient's face Flex connector (accordion) may be used as tubing extender for ETT Check and document the status of the eyes, nose, and chin when prone Keep the head and neck in the neutral position Intraoperative spinal cord monitoring should be considered Evoked-potential monitoring may be used Consider TIVA if neurophysiological monitoring Consider BIS or Massimo to monitor depth of anesthesia if using TIVA Check with surgeon regarding use of muscle relaxants The risk of postoperative visual loss is increased in patients undergoing prone spinal surgery ​ Intraoperative: ​ ​ The surgeon might request Valsalva maneuver (sustained inspiration at 30–40 cm H2O) to test the integrity of the repair Somatosensory evoked potentials: potentials measured over the sensory cortex from stimuli applied to the posterior tibial nerves. SSEPs are transmitted via the posterior column of the spinal cord, around the territory of the posterior spinal arteries supplied by the posterior third of the cord Motor evoked potentials: current stimuli are applied to the motor cortex and measured. MEPs are incompatible with profound muscle relaxation. All anesthetic vapors reduce MEP amplitude in a dose-dependent manner The spinal cord may be at risk if the amplitude of somatosensory evoked potentials (SSEPs) are reduced to <50% of baseline values Avoid large volume resuscitation due to prone positioning Position: Prone Duration: 2-4 hours EBL: 25-500 mL ​ Postoperative: ​ Pain management ​ Complications: ​ Bleeding Infection Dural tear Cerebrospinal fluid leak Nerve root damage Injury to retroperitoneal structures Postoperative visual loss Postoperative respiratory complications Abdominal organ dysfunction ​ 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.). ​ Robert WA Nowicki, FRCA, Anaesthesia for major spinal surgery, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 4, August 2014, Pages 147–152, https://doi.org/10.1093/bjaceaccp/mkt041 ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Orthopaedic Surgical Videos Posterior Lumbar Laminectomy and Fusion Spine Institute of North America Endoscopic Lumbar Laminotomy SpineTreatmentCenter Surgical Procedures - Lumbar Laminectomy & Discectomy

CARDIOVERSION ​ Cardioversion is a medical procedure used to restore a normal heart rhythm in patients with certain types of abnormal heartbeats, or arrhythmias. The most common arrhythmias treated with cardioversion are atrial fibrillation and atrial flutter. The procedure can be performed using electrical or pharmacological methods. ​ Electrical cardioversion: This method involves delivering a controlled electric shock to the heart through electrodes placed on the patient's chest. The shock momentarily stops the heart's electrical activity, allowing the heart's natural pacemaker to regain control and restore a normal rhythm. Electrical cardioversion is performed under sedation or short-acting general anesthesia to ensure the patient's comfort. Pharmacological cardioversion: This method involves using antiarrhythmic medications to restore a normal heart rhythm. These medications can be administered orally or intravenously, depending on the patient's condition and the specific drug used. Pharmacological cardioversion may be used in cases where electrical cardioversion is not appropriate or has not been successful. ​ Effective depolarization of a critical mass of the heart terminates the arrhythmia, allowing normal sinus rhythm to resume. The pulse is delivered synchronously to the QRS, ​ Before the procedure, the patient will undergo a thorough evaluation, including a review of medical history, a physical examination, and diagnostic tests such as an electrocardiogram (ECG) or echocardiogram. The physician may also prescribe anticoagulant medications for several weeks before and after the procedure to reduce the risk of blood clots and stroke. ​ After the procedure, the patient will be monitored to ensure that the heart rhythm has returned to normal and that there are no complications. The healthcare team may prescribe medications to help maintain a normal heart rhythm and reduce the risk of future arrhythmias. ​ Anesthetic Implications for Cardioversion ​ Anesthesia type: Brief general anesthesia, deep sedation ​ Airway: ETT rarely needed ​​ Preoperative: ​ ​ Adequate anticoagulation in patients with AF Assess the presence or absence of hemodynamic instability In the emergency patient, full-stomach precautions may be needed​ Elective cardioversions are often performed on patients who have failed drug therapy Assess the presence of CAD, CHF, and valvular disease Have emergency airway equipment, oxygen, suction, and resuscitation medications Cardioversion is painful, ensure adequate sedation TEE/ECHO can help detect left atrial appendage thrombus If a thrombus is identified, cardioversion is canceled Ensure the patient is NPO and not a full stomach Ensure the head of the bed is easily accessible in case of airway compromise Stay clear of the patient prior to the delivery of synchronized shock ​ Intraoperative: ​ Maintain a patent airway and limit apnea Duration < 30 minutes Position: Supine with defibrillator pads No blood loss Profound bradycardia can occur after cardioversion ​ Postoperative: ​ Monitoring of cardiac rhythm Check for full recovery of airway reflexes Perform neurological exam ​ Complications: ​ Stroke Embolic event Skin burns (thermal injury) New arrhythmias Acute pulmonary edema Loss of airway Severe bradycardia Hypertension Catecholamine surge Myocardial ischemia Recall/awareness Myalgias ​ ​ Sources: Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Dr.G Bhanu Prakash Cardioversion for Atrial Fibrillation Alila Medical Media Cardioversion (Electrical) ICU Advantage Defibrillate, Cardiovert, Pace

ANTERIOR CERVICAL DISCECTOMY AND FUSION (ACDF) ​ Anterior Cervical Discectomy and Fusion (ACDF) is a surgical procedure that aims to relieve pain, weakness, or numbness caused by a herniated or degenerated cervical disc. The cervical spine consists of seven vertebrae (C1 to C7) in the neck region, and discs are the cushion-like structures located between each vertebra. These discs can become damaged or worn out over time, leading to issues like herniation, compression of spinal nerves, or spinal cord compression. ​ The ACDF procedure is performed by approaching the cervical spine from the front (anterior) of the neck. ​ Recovery from ACDF surgery varies from patient to patient but typically takes several weeks to months. During this period, the patient may be required to wear a cervical collar to restrict neck movement and promote healing. Physical therapy is often recommended to help regain strength and flexibility in the neck muscles. ​ Anesthetic Implications for ACDF ​ Anesthesia type: General anesthesia with ETT. Partial or total intravenous anesthesia (TIVA) to optimize neuromonitoring ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Baseline neurologic assessment of sensory and motor function Assess cervical range of motion Patients may be difficult to intubate due to the inability to place in the sniffing position Intubate with the head in the neutral position Consider having a video laryngoscope or fiberoptic bronchoscopy Spinal cord trauma may be associated with loss of sympathetic tone, which can cause peripheral vasodilation and bradycardia Fractures above C5 may result in quadriplegia and loss of phrenic nerve function Manipulation of the head and neck could produce permanent injury If an autograft is being utilized, the hip is also prepped Patients are often on chronic pain medications Find out if the surgeon wants the patient relaxed by neuromuscular blockers Shared airway with surgeon ​​ ​ Intraoperative: ​ ​ Gel roll is frequently placed under the shoulders (enhances neck extension and exposure) Neurologic monitoring may be used during the ACDF ​Somatosensory evoked potentials (SSEPs) monitoring may be used. SSEPs assess the integrity of the posterior spinal cord Volatile anesthetics over 0.5 MAC decrease amplitude and increase the latency of SSEP waveforms (false positive) Motor evoked potentials (MEPs) monitoring may be used. MEPs assess the integrity of the anterior spinal artery MEPs are affected by neuromuscular blocking agents The bispectral index (BIS) monitor can be used Tongue lacerations from MEPs can occur. Apply tongue protection Duration: 1-1.5 hours per level Position: Supine with arms tucked EBL 50-500 ml Fluoroscopy or portable X-ray is used Controlled hypotension may be requested to reduce bleeding ​ Postoperative: Extubation/emergence: Avoid coughing and bucking Perform neurologic exam Recurrent laryngeal nerve injury is associated with stridor and increased risk of aspiration Watch for postoperative hematoma and airway compromise Cervical collar may be utilized to allow bone graft healing ​ ​ Complications: ​ Acute spinal cord injury Esophageal perforation Infection Bleeding Retropharyngeal edema Quadriplegia Carotid or jugular injury Myelopathy Nerve injury​ Recurrent laryngeal nerve injury Airway edema Tracheal laceration Pneumothorax Chronic pain Thrombophlebitis Nonunion of the cervical vertebrae Venous air embolism Dural tear Superior vena cava syndrome Postoperative dysphagia Horner's syndrome Bone graft migration ​ 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 Legal Graphicworks, LGW Mediaworks Anterior Cervical Discectomy and Fusion 3D ShimSpine Anterior Cervical Discectomy and Fusion Randale Sechrest Cervical Spine Anatomy

BILATERAL SALPINGO OOPHERECTOMY (BSO) ​ Bilateral Salpingo-Oophorectomy (BSO) is a surgical procedure that involves the removal of both fallopian tubes (salpingectomy) and both ovaries (oophorectomy) from a woman's body. This surgery is typically performed due to various medical reasons, such as the presence of ovarian cancer, endometriosis, benign ovarian tumors or cysts, ectopic pregnancy, or as a preventive measure for women with a high risk of developing ovarian cancer due to genetic factors (e.g., BRCA1 or BRCA2 gene mutations). ​ Indications for BSO: Ovarian cancer: BSO is often performed when a woman is diagnosed with ovarian cancer or has a high risk of developing it due to a genetic predisposition. Endometriosis: In severe cases of endometriosis, BSO may be performed to alleviate pain and other symptoms. Benign ovarian tumors or cysts: When non-cancerous growths cause pain, discomfort, or other complications, BSO may be recommended. Ectopic pregnancy: In rare cases, BSO may be necessary if an ectopic pregnancy has caused significant damage to the fallopian tube and ovary. Prophylactic surgery: BSO may be performed as a preventive measure in women with a strong family history of ovarian cancer or those who carry BRCA1 or BRCA2 gene mutations. ​ BSO can be performed using different surgical techniques, such as: ​ Laparotomy: This is an open surgery where a large incision is made in the lower abdomen to access the pelvic organs. This approach is used in cases where the surgeon needs a clear and direct view of the pelvic area, or when extensive surgery is anticipated. Laparoscopy: This is a minimally invasive procedure in which small incisions are made in the abdomen, and a laparoscope (a thin tube with a light and camera) is inserted to view the pelvic organs. Special surgical instruments are then used to perform the surgery. Laparoscopy generally has a shorter recovery time and fewer complications compared to laparotomy. Robotic-assisted surgery: This technique involves the use of a robotic system that allows the surgeon to perform the surgery through small incisions with greater precision and control. This approach combines the advantages of laparoscopy with enhanced dexterity and visualization. ​ The recovery time and possible complications of BSO vary depending on the surgical approach used and the individual patient's health. Some of the potential complications include infection, bleeding, damage to nearby organs, and anesthesia risks. After BSO, a woman will no longer have menstrual periods and will experience menopause, as her body will no longer produce the hormones estrogen and progesterone. ​ Premenopausal women who undergo a bilateral salpingo-oophorectomy are placed into surgical menopause. ​ The sudden loss of estrogen will trigger an abrupt premature menopause that may involve severe symptoms of hot flashes, vaginal dryness, painful intercourse, and loss of sex drive. Hormone replacement therapy (HRT) may be considered to alleviate menopausal symptoms and reduce the risk of certain health issues related to the lack of these hormones. ​ Anesthetic Implications for Bilateral Salpingo-Oophorectomy (BSO) ​ Anesthesia type: General with ETT ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ The ovaries are the female pelvic reproductive organs responsible for the production of sex hormones Ovarian carcinoma is usually diagnosed at a late stage Patients may have ascites and/or pleural effusion (respiratory compromise) Cardiotoxicity can result from doxorubicin chemotherapy Cisplatin can cause peripheral neuropathy RSI is usually indicated for patients with an ectopic pregnancy ​ Intraoperative: ​ For an abdominal approach, the patient is placed in the supine position For a laparoscopic or vaginal approach, the patient is placed in the lithotomy position Sciatic and femoral nerve injuries may occur in the lithotomy position Intraoperative insufflation complications (laparoscopic case) ​ Postoperative: ​ Pain management PONV prophylaxis ​ Complications: ​ Infection Hemorrhage Injury to internal organs (bowel, bladder, ureter, blood vessels, and nerves) PONV Deep vein thrombosis Adhesion formation Incisional hernia Ovarian remnant syndrome ​ 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 TVASurg Laparoscopic bilateral salpingo-oophorectomy (BSO) Dr. R. K. Mishra Bilateral Salpingooophorectomy Tanushree Rao Salpingoopherectomy for beginners