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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

EXPLORATORY LAPAROTOMY ​ ​ An exploratory laparotomy is a surgical procedure where a large incision is made in the abdomen to allow a surgeon to visually examine and investigate the organs inside the abdominal cavity. ​ During the procedure, the patient is put under general anesthesia. The surgeon then makes an incision, usually in the midline of the abdomen, to access the abdominal organs. The stomach, liver, gallbladder, spleen, pancreas, kidneys, intestines, and reproductive organs can all be checked for signs of disease, injury, or abnormality. ​ The procedure may allow for immediate treatment of any problems that are discovered. For example, if a tumor is found, it may be removed during the same operation. If a definitive diagnosis cannot be made during the surgery, the surgeon may take a biopsy of tissue for further examination. ​ Postoperatively, patients usually need to stay in the hospital for several days for monitoring and recovery. ​ With the advancements in minimally invasive procedures such as laparoscopy and imaging technologies, the need for exploratory laparotomy has decreased, but it's still considered an important tool when other diagnostic methods fail or in emergency situations. ​ Anesthetic Implications for Exp Lap ​ Anesthesia type: General, combined epidural and general anesthesia ​ Airway: Endotracheal tube ​​ Preoperative: ​ Patients with perforation, peritonitis, and obstruction are likely to need emergency laparotomy High risk for the pulmonary aspiration of gastric contents Patients with gastrointestinal stasis should be considered full stomach precautions Consider the availability of rapid infusion device Consider the placement of an arterial line Two large-bore peripheral intravenous (IV) lines are preferred Previous chemotherapy may be associated with anemia, renal, hepatic, pulmonary toxicity, and cardiomyopathy ​ Intraoperative: ​ ​ Potential for significant fluid shifts and blood loss Warm fluids Prevent hypothermia during long operations Duration: 1-4 hours Position: Supine with arms out ​ Postoperative: ​ ​Pain management Epidural PCA ​ Complications: ​ Bleeding Infection Atelectasis Pneumonia Venous thromboembolism (VTE) PONV Pulmonary function is impaired after abdominal surgery Injury to abdominal organs Formation of adhesions ​ 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 JOMI - Journal of Medical Insight Exploratory Laparotomy Focus Medica Abdomen Anatomy Anatomy Made Easy Anatomy Dissection of the Abdominal Cavity

TONSILLECTOMY AND ADENOIDECTOMY (T&A) A Tonsillectomy and Adenoidectomy , commonly referred to as T&A, are surgical procedures to remove the tonsils and adenoids. These are typically performed to address chronic infections or breathing problems. ​ Tonsillectomy: This involves the removal of the tonsils, two small glands located in the back of your throat. Tonsillectomies are often recommended for patients who experience frequent bouts of tonsillitis or other tonsil-related issues. Adenoidectomy: This surgery involves the removal of the adenoids, which are small lumps of tissue at the back of the nose above the roof of the mouth. Adenoids help fight off infections in young children but become less important as a child gets older. An adenoidectomy is often recommended if the adenoids are enlarged and causing breathing difficulties, chronic infections, or other complications. ​ Clinical indications for a T&A include upper airway obstruction, obstructive sleep apnea with snoring, massive hypertrophy, and chronic upper respiratory infection (URI). Anesthetic Implications for Tonsillectomy and Adenoidectomy ​ Anesthesia type: General ​ Airway: ETT, oral RAE may be used, LMA ​​ Preoperative: ​ ​ The majority of these patients are pediatric Patients may have obstructive sleep apnea (OSA) OSA patients may have cardiovascular involvement (pulmonary hypertension, altered right ventricular diastolic function, arrhythmias) Suggestive of OSA: mouth breathing, daytime somnolence, nighttime awakening, snoring ETT is secured to center of the lower jaw An anticholinergic agent may be administered to decrease oral secretions Muscle relaxation is not needed ​​ Intraoperative: ​ "Shared airway" The mouth is retracted open by a surgical mouth gag and the tongue is depressed Surgeon normally places a throat pack in the hypopharynx Position: Supine, with a shoulder roll used to extend the head, arms tucked, bed turned 90 degrees If cautery or laser is used, airway fire is a risk. Decrease FiO2 to 30%. Duration: 30 minutes EBL 10-200 mL ​ Postoperative: ​ Surgeon will insert an orogastric tube to suction out the stomach Mouth gag is removed Smooth emergence Avoid airway obstruction and aspiration PONV prophylaxis ​​ Complications: ​ Bleeding requiring emergent re-exploration Laryngospasm Hypoxemia Airway edema Accidental extubation Compression of ETT Aspiration Tooth/dental damage ​ ​ 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 Nucleus Medical Media Tonsillectomy & Adenoidectomy Vik Veer - ENT Surgeon Watch Tonsils & Adenoids being Removed University of Kentucky ENT Anesthesia

GASTRIC BYPASS (ROUX EN Y) ​ A gastric bypass , specifically the Roux-en-Y procedure, is a type of weight-loss (bariatric) surgery. It is usually performed when diet and exercise haven't worked or when you have serious health problems because of your weight. ​ This procedure alters the way your small intestine and stomach handle the food you eat. After the surgery, your stomach will be smaller. You'll feel full with less food. Also, the food you eat won't go to some parts of your stomach and small intestine, which absorbs nutrients. ​ Procedure Creation of a small pouch in the stomach: The surgeon uses a laparoscope (a long, thin tube with a high-intensity light and a high-resolution camera at the front) to make several small incisions in the abdomen. They then cut across the top of your stomach, sealing it off from the rest of your stomach. Bypass: The surgeon then cuts the small intestine and sews part of it directly onto the small stomach pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it. Reconnecting the intestine: The surgeon connects the rest of the stomach to the lower part of the small intestine. This bypasses the majority of the stomach and the first section of the small intestine (duodenum), so that the second part (jejunum) can still absorb some nutrients from food. ​ Anesthetic Implications for Gastric Bypass ​ Anesthesia type: General ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Most painful bariatric procedure Assess for difficult airway Consider video laryngoscopy Difficult or failed intubation is more common in obese patient OSA can be associated with pulmonary hypertension Obesity affects every organ system Patients with centralized obesity tend to have less favorable airway anatomy Special attention is needed in obese patients regarding airway and cardiorespiratory status Protect pressure areas because pressure sores and neural injuries are common in obese patients Tracheal intubation should be performed in all patients undergoing laparoscopic bariatric surgery ​ Intraoperative: ​ Multimodal analgesic technique Most anesthetic medications are highly lipophilic The supine position is not well tolerated by a morbidly obese patient Atelectasis is common after induction of anesthesia of morbidly obese The reverse Trendelenburg position maximizes oxygenation because it increases functional residual capacity (FRC) Duration: 1-3 hours Position: Supine and reverse Trendelenburg, arms abducted Bougie is used to size the pouch (enable the surgeon to delineate the anatomy to separate and anastomose the stomach) Methylene blue might be used to check for leaks Body habitus and a pneumoperitoneum can result in high peak airway pressures Tidal volume 6–8 ml kg−1 based on IBW, and a sufficient level of PEEP should be applied (5–10 cmH2O) ​ Postoperative: ​ Obese patients are at higher risk for postoperative complications TAP block for pain management Optimal analgesia Wound care Deep vein thrombosis prophylaxis Fluid management Patients with obesity were at high risk of airway obstruction, hypoventilation and regurgitation at extubation Neuromuscular block must be reversed fully at the end of surgery before extubation ​ Complications: ​ Bleeding Nausea and vomiting Thromboembolic events Aspiration Postoperative wound infection Risk of anastomotic leaks Longer-term vitamin and mineral deficiencies ​ 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. ​ Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian SM. Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article. Anesth Pain Med. 2017 Jul 11;7(4):e57568. doi: 10.5812/aapm.57568. PMID: 29430407; PMCID: PMC5797674. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Mayo Clinic Health System Roux-en-Y Gastric Bypass Cleveland Clinic Laparoscopic Roux-en-Y Gastric Bypass University of Kentucky ERAS Anesthesia Keyword Review

MEDIASTINOSCOPY ​ ​ Mediastinoscopy is a surgical procedure that allows a doctor to examine the mediastinum. The mediastinum is the part of the chest that lies between the sternum and the spinal column, and between the lungs. This area contains the heart, esophagus, trachea, lymph nodes, and other vital structures. ​ The procedure is typically performed to diagnose diseases of the lymph nodes of the chest, such as cancer (especially lung cancer), infections, or other disorders. It's often used when imaging studies like CT scans or PET scans reveal abnormalities in the mediastinum that require further investigation. ​ Here's how a mediastinoscopy is generally performed: Preparation: The patient is given general anesthesia so they will be asleep and pain-free during the procedure. Blood tests and imaging studies may be done beforehand to help plan the surgery. Incision: The surgeon makes a small incision (about an inch long) just above the breastbone or on the side of the neck. Inserting the Mediastinoscope: A thin, lighted tube called a mediastinoscope is inserted through the incision. This scope may have a camera attached so the surgeon can view the area on a video screen. Examination and Biopsy: The surgeon uses the scope to examine the mediastinum. Instruments can be passed through the scope to take tissue samples (biopsies) from lymph nodes or other structures. Closure: The incision is then closed with sutures, and a bandage is applied. ​ ​ Anesthetic Implications for Mediastinoscopy ​ Anesthesia type: General anesthesia , epidural ​ Airway: ETT ​​ Preoperative: ​ ​ Mediastinoscopy involves endoscopic visualization of the mediastinum Anterior mediastinal masses can cause distal airway obstructions Patients with anterior mediastinal masses are often unable to lie flat If airway collapse is likely with muscle paralysis, maintain patient spontaneously breathing Anterior mediastinal masses: Catastrophic airway obstruction or cardiovascular collapse on induction of anesthesia Posterior mediastinal masses may cause Horner’s syndrome when excised A left radial arterial line should be used The pulse oximeter may be placed on the patient’s right hand to monitor possible compression of the right innominate artery Enlarged lymph nodes or tumors may compress the trachea and surrounding structures ​ Intraoperative: ​ ​ ​ The lungs possess a rich lymphatic system Important to provide adequate muscle relaxation The biopsy is sent to pathology (the surgeon may decide to wait for the pathology report prior to closing) Position: Supine. The head may need to be flexed or extended Duration: 1 hour The innominate artery may be compressed by the scope, causing decreased blood flow to the right cerebral hemisphere and the right upper extremity May encounter vagally mediated reflex bradycardia secondary to compression of the trachea or great vessels Avoid nitrous oxide due to potential pneumothorax ​ Postoperative: ​ Pain management Assess for airway obstruction ​ Complications: ​ ​ Compression of the innominate artery by the scope Cerebral ischemia Stroke Massive hemorrhage Vascular trauma Pneumothorax Recurrent laryngeal nerve injury Vocal cord paralysis Phrenic nerve injury Venous air embolism Arrhythmias Vagally mediated reflex bradycardia Chylothorax Tracheal injury Esophageal injury Pleural tear Airway obstruction ​ ​ ​ ​ 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. ​ ​ ​ ​ ​​ ​​ Drcrutch Mediastinoscopy Kenhub Lymph Nodes and Vessels of the Mediastinum More Than Skin Deep Anatomy of the Mediastinum Back to Surgical Tips

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) ​ ​ ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It's a procedure used to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. ​ In an ERCP procedure, an endoscope (a long, flexible, lighted tube) is guided through the patient's mouth and stomach, up into the upper part of the small intestine, called the duodenum. A smaller tube (a catheter) is then inserted through the endoscope and into the bile and pancreatic ducts. A dye is injected, and the ducts are then x-rayed to outline the gallstones, other obstructions, tumors, or abnormalities. ​ Besides diagnostic purposes, ERCP can also be used for therapeutic interventions such as removing gallstones from the bile duct or placing a stent (a small tube) to open up a narrowed bile or pancreatic duct ​ Endoscopic sphincterotomy, also known as papillotomy, is a procedure often performed during ERCP (Endoscopic Retrograde Cholangiopancreatography). ​ In this procedure, a small incision (cut) is made in the opening of the bile duct, known as the papilla, or the pancreatic duct. This procedure is performed to enlarge the opening of the duct so that bile or pancreatic juices can flow more easily, or to allow removal of gallstones lodged in the bile duct. ​ Endoscopic sphincterotomy or papillotomy can be a very effective way to treat certain conditions, like gallstones, strictures (narrowing) of the bile duct, or certain tumors. ​ Biliary flow from the common bile duct into the duodenum is controlled by the sphincter of Oddi. ​ Anesthetic Implications for ERCP ​ Anesthesia type: General , TIVA ​ Airway: Endotracheal tube ​​ Preoperative: ​ ERCP combines endoscopy with fluoroscopy Retrograde refers to the direction in which the contrast dye is injected for visualization of bile ducts and pancreas Fluoroscopy/Xray precautions. Use lead aprons and thyroid shields Check for allergies. Contrast dye is used during this procedure Check the patients cervical range of motion Check with the surgeon which side is preferred for ETT taping Eye protection should be used in the prone position Local anesthetics can be administered to numb the back of the throat A mouthpiece (bite block) is inserted to prevent damage to teeth from biting on scope Lowering the chin towards the sternum or jaw thrust can help massage of scope into oropharynx An anticholinergic agent such as Glycopyrrolate can be administered to decrease secretions Patients may have pancreatic disease with associated peritoneal and pleural effusions Hepatic dysfunction may be associated with coagulopathy and altered drug metabolism Liver dysfunction may increase the risk of esophageal varices bleeding ​ Intraoperative: ​ Glucagon may be administered to inhibit intestinal motility and to relax the sphincter of Oddi (decreases biliary pressure) Opioids can cause spasms of the sphincter of Oddi Position: prone with head turned to the side (towards surgeon) Duration: 1-2 hours ​ Postoperative: ​ Pain management ​ Complications: ​ Post-ERCP pancreatitis Bowel or duct perforation Aspiration Bleeding ​ 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 NEJM Group ERCP for Removal of a Stone in the Bile Duct Animated Pancreas Patient Understanding ERCP Animated Pancreas Patient The Role and Anatomy of the Pancreas

ABLATION FOR SVT AND VT ​ Ablation is a medical procedure used to treat certain types of abnormal heart rhythms, such as supraventricular tachycardia (SVT) and ventricular tachycardia (VT). These conditions are caused by abnormal electrical pathways in the heart, which can lead to rapid or irregular heartbeats. Ablation aims to eliminate these abnormal pathways and restore normal heart rhythm. The procedure is typically performed using catheter-based techniques, which involve the use of thin, flexible tubes called catheters. ​ SVT (Supraventricular Tachycardia) Ablation: SVT is an abnormally rapid heart rate originating in the upper chambers of the heart, called the atria. In an SVT ablation, the catheter is inserted into a blood vessel, usually in the groin, and guided through the vascular system into the heart. Once the catheter reaches the heart, the electrophysiologist (a cardiologist specializing in heart rhythm disorders) uses it to create a detailed electrical map to identify the precise location of the abnormal electrical pathway causing the SVT. ​ Once the pathway is identified, the tip of the catheter is used to deliver radiofrequency energy, cryoablation (freezing), or other energy sources to create small, controlled scars in the heart tissue. These scars block the abnormal electrical signals, thus eliminating the cause of the SVT. VT (Ventricular Tachycardia) Ablation: VT is a potentially life-threatening heart rhythm disorder originating in the lower chambers of the heart, called the ventricles. Similar to SVT ablation, in a VT ablation, the catheter is guided through a blood vessel into the heart. The electrophysiologist then maps the abnormal electrical pathways causing the VT. ​ Once the pathways are identified, the catheter delivers energy (typically radiofrequency or cryoablation) to create controlled scars in the heart tissue. These scars disrupt the abnormal electrical signals, thus eliminating the cause of the VT. ​ Both SVT and VT ablations are generally considered safe, but like any medical procedure, they do carry some risks. These may include bleeding, infection, blood vessel damage, or complications related to anesthesia. In rare cases, more serious complications may occur, such as damage to the heart's normal electrical system, requiring a pacemaker, or injury to the heart tissue, leading to a hole or tear. Overall, ablation procedures have proven to be effective in treating SVT and VT, significantly reducing symptoms and improving the quality of life for many patients. ​ Anesthetic Implications of Ablation for SVT and VT ​ Anesthesia type: General ETT, LMA, local MAC or TIVA ​ Airway: Endotracheal tube or LMA ​​ Preoperative: ​ Overall cardiovascular and functional status assessment Antiplatelet drugs and anticoagulants use should be noted Be mindful of exposure to nephrotoxic contrast agents in renal insufficiency patients Blood products are normally not required Antibiotics are usually not indicated An invasive arterial line can be useful , but not required Defibrillator pads should be properly positioned Antiarrhythmic drugs are normally stopped prior to surgery to make the dysrhythmias more inducible Antiarrhythmic agents can cause QTc prolongation Ventricular tachycardia often arises from the right ventricular outflow tract (RVOT) Ablations for SVT and VT commonly only require right heart access A femoral artery sheath may be placed for left-sided ablation (retrograde approach), and pressure can be transduced from the sheath If left-sided study and ablation is planned, heparinization is required to reduce the risk of thromboembolism ​ ​ Intraoperative: ​ The first part of the case involves mapping the myocardium to identify the tissue responsible for initiating the dysrhythmia Anesthetics can depress hemodynamic stability and decrease the inducibility of VT Isoproterenol can be used during an electrophysiology (EP) study to provoke or induce the arrhythmia Isoproterenol is a non-selective beta agonist with chronotropic, dromotropic, inotropic, and vasodilatory effects Hemodynamic fluctuation is normally encountered Be aware of the C-arm when it is in motion Be mindful of Ionizing radiation dangers An esophageal temperature probe can monitor increases in temperature and decrease the risk of esophageal injury Phrenic-nerve pacing may be used to locate the nerve and avoid damage from ablation Position: Supine with arms tucked Duration: 1-3 hours ​EBL minimal ​ ​ Postoperative: ​ ​ ​Monitor for signs of fluid overload or heart failure The patient may lie flat for several hours ​ Complications: ​ ​Bleeding Retroperitoneal bleeding Pericardial effusion Cardiac tamponade Cardiac perforation Femoral vein hematoma Puncture of femoral artery Arrhythmias Complete heart block Pneumothorax Stroke Myocardial infarction Embolism Hemodynamic fluctuation Coronary spasm Esophageal injury Atrial-esophageal fistula Aortic perforation ​​ 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 Nucleus Medical Media Catheter Ablation The Visual Surgery Cardiac Ablation Eastsidearrhythmia Catheter Ablation Animation Zero To Finals Understanding Supraventricular Tachycardia Strong Medicine Ventricular Tachycardia Strong Medicine Distinguishing VT from SVT with aberrancy

CARPAL TUNNEL RELEASE ​ Carpal Tunnel Release is a surgical procedure performed to relieve the pressure on the median nerve in the wrist, which can cause pain, numbness, and tingling in the hand and fingers. This condition is called carpal tunnel syndrome (CTS) and is caused by the compression of the median nerve in the wrist. ​ The procedure involves making a small incision on the palm side of the wrist and cutting the transverse carpal ligament to create more space for the median nerve. This can be performed through a traditional open incision or through a minimally invasive endoscopic procedure. ​ The recovery from carpal tunnel release surgery varies from person to person, but most people experience a significant improvement in their symptoms after the procedure. Physical therapy and hand exercises may be recommended to help improve wrist and hand strength and range of motion. ​ ​ Anesthetic Implications for Carpal Tunnel Release ​ Anesthesia type: MAC sedation and a local anesthetic. Regional anesthesia with Bier block or brachial plexus block ​ Airway: Natural airway ​​ Preoperative: ​ ​ Never use Bupivacaine with a Bier block due risk of cardiotoxicity Place the blood pressure cuff on the nonoperative arm Intravenous regional anesthesia is suitable for procedures that are < 1 hour ​ Intraoperative: ​ Tourniquet may be used Tourniquet pain normally begins 45 minutes after inflation Tourniquet pain is unresponsive to analgesics Supine position with the affected arm extended on a hand table Duration 30-90 minutes EBL minimal ​ Postoperative: ​ Splint is applied at the end of the case Pain management ​ Complications: ​ Neurovascular compromise Hematoma Infection Local anesthetic toxicity Tendon/nerve laceration ​ ​ 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 Medical Legal Art Carpal Tunnel Surgical Release Osmosis from Elsevier Carpal Tunnel Syndrome Regional Anesthesiology IVRA (Intravenous Regional Anesthesia)

ARTHROSCOPY- KNEE ​ Knee arthroscopy is a minimally invasive surgical procedure that allows orthopedic surgeons to examine and treat issues within the knee joint. It involves the use of an arthroscope, a small, flexible tube with a camera and light source at its end, to visualize the internal structures of the knee joint without the need for large incisions. The procedure is commonly used to diagnose and treat various knee problems, such as torn meniscus, damaged cartilage, ligament injuries, or inflammation. ​ Meniscectomy and/or debridement are commonly performed with arthroscopy. Cruciate ligament reconstruction is often performed with arthroscopic assistance. ​ Anesthetic Implications for Knee Arthroscopy ​ Anesthesia type: General ETT, LMA, or peripheral nerve block ​ Airway: Endotracheal tube or LMA ​ Preoperative: A thorough preoperative assessment should be conducted to identify any underlying medical conditions, allergies, or contraindications to anesthesia. This includes a detailed medical history, physical examination, and appropriate laboratory tests. ​ The choice of anesthesia technique depends on factors such as patient preference, medical history, surgeon preference, and the anticipated duration of the procedure ​​ Intraoperative: ​ A tourniquet may be used to provide a bloodless surgical field Maximum safe tourniquet time is less than 2 hours ​Duration: 30-90 minutes ​Position: Supine with arms out EBL: Minimal ​ ​ Postoperative: ​ Maintain knee immobilization with a knee immobilizer ​ Knee arthroscopy is often performed as an outpatient procedure, with patients discharged on the same day as the surgery ​ Complications: ​ Hemarthrosis Thrombophlebitis Numbness Infection Stiffness ​​ 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 Armando Hasudungan Clinical Anatomy - Knee Orthochannel Knee Arthroscopy Malek Racy Knee Arthroscopy - Teaching Video

HYSTERECTOMY ​ ​ A hysterectomy is a surgical procedure that involves removing a woman's uterus (also known as the womb), which is where a fetus would develop during pregnancy. This surgery can sometimes also involve the removal of other related structures such as the fallopian tubes (a bilateral salpingectomy), ovaries (oophorectomy), and the cervix (this is typically included unless a "supracervical" or "partial" hysterectomy is performed). ​ There are a few different types of hysterectomies, depending on what structures are removed: Total hysterectomy: This is the removal of the entire uterus, including the cervix. Most hysterectomies are total. Subtotal or partial hysterectomy: The upper part of the uterus is removed but the cervix is left in place. Radical hysterectomy: This is performed when certain cancers are present. The uterus, cervix, the tissue on both sides of the cervix, and the upper part of the vagina are removed. ​ A hysterectomy can be performed in a few different ways: Abdominal hysterectomy: This involves making a large incision in the abdomen to remove the uterus. Vaginal hysterectomy: This involves making an incision in the vagina to remove the uterus. Laparoscopic hysterectomy: This involves making several small incisions in the abdomen. A laparoscope (a thin, lighted tube with a camera on the end) is inserted into one of the incisions. The uterus is removed piece by piece through the small incisions. Robotic hysterectomy: This is similar to a laparoscopic procedure but it is performed with a machine controlled by the surgeon. ​ The procedure is often recommended when other treatment options have not worked or are not possible, and conditions that might require a hysterectomy include certain types of cancer (like uterine, ovarian or cervical cancers), endometriosis, uterine fibroids, chronic pelvic pain, and uterine prolapse. ​ Anesthetic Implications for Hysterectomy ​ Anesthesia type: General, neuraxial ​ Airway: ETT ​​ Preoperative: ​ ​ The patient may be hypovolemic from blood loss or bowel prep The blood supply to the pelvis is largely derived from the internal ileac (hypogastric) artery Extensive collateral circulation to pelvic viscera organs can cause significant bleeding during pelvic dissection or obstetric hemorrhage Sensory innervation from the pelvic viscera (including the uterus) arises from T10-L4 spinal cord segments Ventilatory alterations from laparoscopy: Decreased functional residual capacity, increased airway pressures, decreased lung compliance, and right mainstem intubation Carbon dioxide absorption during laparoscopic cases can be associated with increased plasma catecholamines ​ Intraoperative: ​ Prevent nerve injuries Monitor for blood loss Maintain hemodynamic stability Abdominal incisions have increased insensible fluid loses Position for abdominal hysterectomy: supine Position for total laparoscopic and robotic hysterectomy: Supine with steep Trendeleburg Position for vaginal hysterectomy: Lithotomy Duration for abdominal and vaginal hysterectomy: 1-3 hours Duration for total laparoscopic and robotic hysterectomy: 2-6 hours EBL for elective hysterectomy: 200-600 mL Injection of vasopressin into uterus can reduce blood loss ​ Postoperative: ​ A cystoscope may be inserted to assess for bladder perforation PONV prophylaxis Pain management ​ Complications: ​ Infection Bleeding Urinary incontinence Injury to nearby organs (bladder, ureters, pelvic structures) DVT PE ​ ​ Sources: ​ 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 Chelsea and Westminster Hospital Abdominal Hysterectomy Dr Matt & Dr Mike Female Reproductive System Siebert Science Female Reproductive System

KYPHOPLASTY & VERTEBROPLASTY ​ ​ Kyphoplasty and vertebroplasty are minimally invasive procedures used to treat vertebral compression fractures, which are most commonly caused by osteoporosis, cancer, or injury. These procedures aim to reduce pain, stabilize the fracture, and restore some or all of the lost vertebral body height due to the compression fracture. ​ Vertebroplasty: In this procedure, a doctor injects a special cement mixture into the fractured bone. The doctor uses imaging guidance to guide a thin needle containing the special cement through the skin and into the vertebral body. Once the needle is in the correct position, the doctor injects the cement into the fractured bone. The cement hardens quickly, stabilizing the fracture and providing immediate pain relief in many cases. Kyphoplasty: This procedure is similar to vertebroplasty but involves an additional step. Before injecting the bone cement, the doctor inserts a small, inflatable balloon into the vertebral body. The balloon is then inflated to create a cavity. Once the cavity is created, the balloon is deflated and removed, and the cement is injected into the cavity. The aim of this procedure is not only to relieve pain and stabilize the fracture but also to restore the height and angle of kyphosis of the vertebral body. ​ Both vertebroplasty and kyphoplasty are collectively called vertebral augmentations. ​ Anesthetic Implications for Kyphoplasty & Vertebroplasty ​ Anesthesia type: General anesthesia, TIVA, MAC, local anesthesia with sedation ​ Airway: ETT ​​ Preoperative: ​ ​ Performed under fluoroscopic or CT guidance Have lead aprons and thyroid shields available Elderly patients with comorbidities Assess patient's airway and history of sleep apnea Prone positioning may result in a significant fall in cardiac output Eye protection for general cases ​ Intraoperative: ​ ​ Trocar is passed percutaneously into the affected vertebral body The passage of the trocar through the periosteum of the vertebral body is painful Position: Prone with arms extended and flexed (“Superman position”) Duration: 30-60 minutes Maintain cervical neutrality Be mindful of close proximity of the iliac vessels, inferior vena cava, and descending aorta to the thoracolumbar vertebral bodies ​ Postoperative: ​ Pain management ​ Complications: ​ Loss of airway Infection Bleeding Increased back pain Nerve damage Complications related to the bone cement Cement leakage into surrounding areas Pulmonary emboli ​ 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 Vertebroplasty and Kyphoplasty Seattle Science Foundation Vertebroplasty & Kyphoplasty Demonstration #1 Seattle Science Foundation Vertebroplasty & Kyphoplasty Demonstration #2

GASTRIC SLEEVE ​ A gastric sleeve, also known as a sleeve gastrectomy, is a type of bariatric surgery that is often used as a treatment for severe obesity when diet and exercise have not been effective. This surgery involves removing about 75-80% of the stomach, leaving a thin vertical "sleeve" that is about the size of a banana. ​ The procedure is typically done laparoscopically, which means it's minimally invasive. The surgeon makes small incisions and uses a camera and special tools to perform the operation. ​ The main goal of the gastric sleeve surgery is to reduce the size of the stomach, which in turn limits the amount of food a person can eat at one time. The operation also impacts gut hormones and other factors that affect hunger, satiety, and blood sugar control. This surgery does not involve any bypass of the intestines, so nutrient absorption is not as affected as with some other types of weight-loss surgeries. ​ Anesthetic Implications for Gastric Sleeve ​ Anesthesia type: General ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​​ Sleeve gastrectomy is a permanent method of reducing the size of the stomach Assess for difficult airway Consider video laryngoscopy Difficult or failed intubation is more common in obese patient OSA can be associated with pulmonary hypertension Obesity affects every organ system Patients with centralized obesity tend to have less favorable airway anatomy Special attention is needed in obese patients regarding airway and cardiorespiratory status Protect pressure areas because pressure sores and neural injuries are common in obese patients Tracheal intubation should be performed in all patients undergoing laparoscopic bariatric surgery ​ Intraoperative: ​ Multimodal analgesic technique Most anesthetic medications are highly lipophilic The supine position is not well tolerated by a morbidly obese patient Atelectasis is common after induction of anesthesia of morbidly obese The reverse Trendelenburg position maximizes oxygenation because it increases functional residual capacity (FRC) Duration: 1-2 hours Position: Supine and reverse Trendelenburg, arms abducted A bougie is placed orally against the lesser curvature of the stomach to size the pouch Body habitus and a pneumoperitoneum can result in high peak airway pressures Tidal volume 6–8 ml kg−1 based on IBW, and a sufficient level of PEEP should be applied (5–10 cmH2O) ​ Postoperative: ​ Obese patients are at higher risk for postoperative complications TAP block for pain management Optimal analgesia Wound care Deep vein thrombosis prophylaxis Fluid management Patients with obesity were at high risk of airway obstruction, hypoventilation and regurgitation at extubation Neuromuscular block must be reversed fully at the end of surgery before extubation ​ Complications: ​ Bleeding Nausea and vomiting Thromboembolic events Aspiration Postoperative wound infection Gastric leak ​ 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. ​ Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian SM. Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article. Anesth Pain Med. 2017 Jul 11;7(4):e57568. doi: 10.5812/aapm.57568. PMID: 29430407; PMCID: PMC5797674. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Duke Health Gastric Sleeve Surgery SAGES Laparoscopic Sleeve Gastrectomy University of Kentucky ERAS Anesthesia Keyword Review