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COLONOSCOPY ​ A colonoscopy is a medical procedure that allows a doctor, usually a gastroenterologist, to examine the inner lining of the large intestine (rectum and colon). They use a thin, flexible tube called a colonoscope to view the colon. This device has a small camera attached to its end, which transmits images to a monitor for the doctor to review. ​ It may be performed for either diagnostic or therapeutic purposes. ​ A grounding pad may need to be placed for cautery excision. ​ Here are the key steps in the procedure: Preparation: Before the procedure, patients need to clean out your colon (colon prep) to give the doctor a clear view. This usually involves a liquid diet for 1 to 3 days before the procedure and taking a strong laxative or over-the-counter enema kit. Sedation: Before the colonoscopy starts, patients receive a sedative to help them relax and reduce discomfort. Procedure: The doctor will slowly insert the colonoscope into the rectum and guide it into the colon. Air or carbon dioxide will be introduced to expand the colon for a better view. Polyp Removal & Biopsy: If the doctor finds polyps (abnormal growths), they can remove them during the procedure using tiny tools passed through the scope. Similarly, if other abnormal tissues are found, they can be sampled (biopsy) for further testing. ​ Colonoscopies are often used to diagnose gastrointestinal symptoms, screen for colon cancer, and follow up on a positive stool test. The American Cancer Society recommends that people at average risk of colon cancer begin regular screenings at age 45, ​ Anesthetic Implications for Colonoscopy ​ Anesthesia type: TIVA, sedation ​ Airway: Oral airway, nasal ariway ​​ Preoperative: ​ ​ Patients receive a bowel prep and present with dehydration and hypovolemia Oxygen is administered via nasal cannula or simple face mask CO2 monitoring is a helpful adjunct Airway equipment and emergency medications must be available Risk of aspiration for patients with obstruction Patients with colon cancer are likely to be anemic Metastatic colon cancer maybe associated with concomitant organ dysfunction (liver and lungs) ​ Intraoperative: ​ ​ Vagal effect and bradycardia may occur from colon insufflation Position: left lateral position, with knees pulled up and legs bent The doctor may ask to press on abdomen (stimulating) Insufflation of the colon can decrease functional residual capacity (FRC) Duration 15-60 minutes EBL none to minimal. Unless associated with underlying GI bleed or coagulopathy ​ Postoperative: ​ Recovery period ​ Complications: ​ Bleeding Colonic perforation Airway obstruction Desaturation ​ 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 You and Colonoscopy What happens during and after a colonoscopy? Olympus Medical Systems Europe Basics of Colonoscopy The Everett Clinic Intravenous Sedation for Endoscopy Colonoscopy

LIPOSUCTION ​ ​ Liposuction is a type of cosmetic surgery that breaks up and removes fat from the body. It is typically used on areas of the body that haven't responded to diet and exercise, such as the: ​ Abdomen Thighs Buttocks Upper arms Back Hips Chest area Calves and ankles Chin and neck ​ This procedure is typically performed under general, regional, or local anesthesia. The surgeon makes a small incision in the skin, and then inserts a thin tube called a cannula into the fat layer beneath the skin. The cannula is attached to a vacuum that suctions out the fat cells. ​ Liposuction is not a treatment for obesity or a substitute for proper diet and exercise. It's also not an effective treatment for cellulite. Rather, it's a way to remove a small amount of excess fat that doesn't go away with traditional weight loss methods. ​ Anesthetic Implications for Liposuction ​ Anesthesia type: General anesthesia, IV sedation with local anesthetic ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Careful body positioning Large-volume (> 5000 mL) resection may require overnight medical observation and monitoring ​ Intraoperative: ​ ​ The use of epinephrine-containing wetting solutions injected in the subcutaneous tissue prior to aspiration of fat reduces perioperative blood loss Limit the amount of peripheral IV fluid administered because the patient is being instilled with large amounts of the wetting solution The wetting solution must be warmed to prevent hypothermia Tumescent (wetting) solution injected into the subcutaneous tissue is absorbed over 48 hours Diuretics may need to be given Watch for fluid shifts and pulmonary edema When epinephrine is given, anticipate an increase in the patient’s blood pressure Mild controlled hypotension may be requested to facilitate hemostasis ​ Postoperative: ​ Smooth emergence Avoid coughing, bucking, or nausea and vomiting Pain management PONV prophylaxis ​ Complications: ​ Infection Scarring Numbness Changes in skin color Fat emboli Fluid overload Local anesthetic toxicity Pulmonary embolism Pulmonary edema Pneumothorax Damage to internal organs Hypothermia ​ ​ 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 The Williams Center How Does Liposuction Work? Aronowitzland Liposuction Surgery American Society of Plastic Surgeons How Liposuction Removes Fat

HYDROCELECTOMY ​ A hydrocelectomy is a surgical procedure used to correct a hydrocele. A hydrocele is a condition in which fluid collects in the sac around the testicle, leading to swelling and discomfort. Hydroceles can occur in males of any age, but they're most commonly seen in newborns and older men . ​ The hydrocelectomy procedure usually involves the following steps: Anesthesia: The patient is given general or spinal anesthesia to prevent any discomfort during the procedure. Incision: The surgeon makes an incision in the scrotum or the inguinal area (just above the scrotum). Drainage of fluid: The surgeon then drains the fluid from the hydrocele sac. Sac treatment: The hydrocele sac may be removed, stitched up or turned inside out and stitched to the back of the testicles (this method is known as the Jaboulay procedure). The choice depends on the surgeon's judgement and the specifics of the case. Closure: The incision is then closed with sutures. ​ Recovery from a hydrocelectomy is generally quick. Patients are often able to go home the same day as the surgery, but there may be instructions to follow, like wearing supportive undergarments and refraining from sexual activity for a certain period of time. ​ Anesthetic Implications for Hydrocelectomy ​ Anesthesia type: General, neuraxial ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ A hydrocele may be accompanied by an inguinal hernia ​ Intraoperative: ​ Manipulation of the genitals can cause sudden and significant vagal bradycardia Have glycopyrrolate and/or atropine available Duration: 30-60 minutes Position: Supine or lithotomy, arms at the side on armboards ​ Postoperative: ​ A scrotal support strap is applied at the end of the case ​ Complications: ​ Infection Bleeding Injury to the testicle or the structures around it ​ 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 Zero To Finals Understanding Hydroceles Asst. Prof. MD. Cüneyd Sevinç Bilateral Hydrocelectomy Surgery Divakar Dalela Hydrocele

LEEP PROCEDURE ​ ​ LEEP stands for "Loop Electrosurgical Excision Procedure." It's a treatment that prevents cervical cancer. Your doctor may recommend a LEEP if your Pap test or a procedure called a colposcopy produced abnormal results. This procedure uses a thin, low-voltage electrified wire loop to cut out abnormal tissue. LEEP allows your doctor to remove abnormal cells and test them for cancer. ​ Here's a step-by-step of how it usually goes: The doctor will first numb your cervix with local anesthesia. A speculum will be inserted into your vagina to hold it open, and the doctor will use a colposcope (a special magnifying instrument) to look at your cervix. The colposcope itself doesn't go inside your vagina. A vinegar-like solution may be applied to your cervix to make the abnormal cells more visible. The doctor will then use the electrified wire loop to remove a thin layer of abnormal cells from your cervix. The removed tissue will be sent to a lab for further examination. ​ ​ Anesthetic Implications for Leep Procedure ​ Anesthesia type: General, local anesthesia, neuraxial block ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ Patients are generally young If pregnant, perform RSI induction ​ Intraoperative: ​ ​ A thin wire loop is inserted into the vagina An electric current is used to remove a wedge of the cervix A local anesthetic and epinephrine solution may be injected (may increase HR and BP) Position: lithotomy position, slight Trendelenburg with arms extended on armboards bilaterally Duration: 30-60 minutes ​ Postoperative: ​ Pain management PONV prophylaxis ​ Complications: ​ Perforation of the uterus Bleeding Infertility Nerve injury from lithotomy position ​ 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 SLUCare Loop Electrosurgical Excision Procedure (LEEP) Suny Caminero MD LEEP (Loop Electrosurgical Excision Procedure) Reproductive Health Library Large Loop Excision of the Transformation Zone

ANAL RECTAL PROCEDURES ​ Anal and rectal procedures are medical or surgical interventions performed to diagnose or treat various conditions affecting the anus or rectum. Some common anal and rectal procedures include: 1) Hemorrhoidectomy: A surgical procedure to remove hemorrhoids, which are swollen and inflamed veins in the anus and lower rectum. This procedure can be done using various techniques, such as conventional surgery, stapled hemorrhoidectomy, or laser surgery. 2) Fissurectomy: A surgical procedure to treat anal fissures, which are tears in the lining of the anus. The surgeon removes the fissure and any surrounding tissue, promoting healing and preventing recurrence. 3) Fistulotomy: A surgical procedure to treat anal fistulas, which are abnormal connections between the anal canal and the skin around the anus. The surgeon opens the fistula, cleans the area, and allows it to heal from the inside out. 4) Pilonidal cyst excision: A surgical procedure to remove a pilonidal cyst, which is an abnormal pocket of skin and hair near the tailbone that can become infected and form an abscess. The surgeon removes the cyst and any surrounding tissue, and the wound is either closed with stitches or left open to heal. 5) Rectopexy: A surgical procedure to correct rectal prolapse, a condition in which the rectum protrudes through the anus. The surgeon repositions the rectum and secures it to the surrounding tissue to prevent it from prolapsing again. ​ These are just a few examples of anal and rectal procedures. Anesthetic Implications for Anal Rectal Procedures ​ Anesthesia type: General anesthesia, local MAC, TIVA, n euraxial (spinal or epidural), or combination anesthesia may be employed ​ Airway: Endotracheal tube or LMA ​​ 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 ​​ ​ Intraoperative: ​ May have to l imit IV fluids to 500 ml. Check with surgeon Nerve supply to anorectal area Sympathetic supply: sympathetic chain to hypogastric plexus(L1 –L5 ) and celiac plexus (T11–L2) Parasympathetic supply comes from ventral rami of S2 –S4 ​​ ​ Postoperative: ​ Local anesthesia is usually injected for postoperative pain relief It is not uncommon to have difficulty completely emptying your bladder after surgery ​ Complications: ​ Urinary retention Bleeding Infection Pain Fecal impaction ​​ ​ 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 Kenhub - Learn Human Anatomy Rectum and Anal Canal: Anatomy MedLecturesMadeEasy Anorectal Disorders

SPINAL CORD STIMULATOR A spinal cord stimulator (SCS) is a medical device used to exert pulsed electrical signals to the spinal cord to control chronic pain. The device, typically implanted under the skin, sends a mild electric current to the spinal cord. Thin wires carry current from a pulse generator to the nerve fibers of the spinal cord. When turned on, the SCS stimulates the nerves in the area where your pain is felt. Pain is replaced by a mild tingling sensation. The device can be turned on and off, and adjusted using an external remote. ​ This therapy is often considered when other methods have failed to relieve pain. It's particularly effective for neuropathic pain, which is pain caused by damage to the nerves. Conditions that may benefit from SCS include chronic leg or arm pain, failed back surgery syndrome, and complex regional pain syndrome. The implantation of a spinal cord stimulator is typically done in two stages. First, a trial stimulator is inserted to determine if it reduces pain. If successful, a permanent stimulator is then implanted. The procedure for implanting a spinal cord stimulator involves inserting the leads through a needle placed in the back near the spinal cord. The leads are connected to a pulse generator, which is placed under the skin in the lower back or buttocks. ​ An SCS provides electrical stimulation to the dorsal column, lateral funiculus, and dorsal roots. Anesthetic Implications for Spinal Cord Stimulator ​ Anesthesia type: TIVA ​ Airway: ETT, spontaneous ventilation ​​ Preoperative: ​ ​ Fluoroscopy/X-ray will be used Make sure patient is comfortably positioned prior to sedation ​​ Intraoperative: ​ Position: "Superman" > prone with arms extended and flexed Duration: 1-2 hours An SCS consists of leads containing electrodes that are placed in the dorsal epidural space The lead is anchored with sutures to the supraspinous ligament and tunneled subcutaneously When the stimulator cords are in place, the patient will be shortly woken up to assess the efficacy of the stimulator During tunnelling of SCS leads and creation of a subcutaneous pocket for pulse generator implantation, general anesthesia (TIVA) is often administereed ​ Postoperative: ​ Procedural pain ​​ Complications: ​ ​Cerebrospinal fluid leak Hematoma Infection Technical complications of device ​ Sources: ​ Bull C, Baranidharan G. Spinal cord stimulators and implications for anaesthesia. BJA Educ. 2020 Jun;20(6):182-183. doi: 10.1016/j.bjae.2020.02.005. Epub 2020 Mar 24. PMID: 33456948; PMCID: PMC7807848. ​ 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 Bionic Medical Institute Animation of Spinal Cord Stimulator Implant Procedure Seattle Science Foundation Spinal Cord Stimulation Procedure Boston Scientific Dr Matt & Dr Mike Chronic Pain and Sensitisation

INGUINAL HERNIA REPAIR ​ ​ An inguinal hernia occurs when part of the intestine or fat pushes through a weak spot in the lower abdominal wall (the inguinal canal). Inguinal hernias are the most common type of hernia and are more common in men. They can be painful, especially when coughing, bending over, or lifting a heavy object. ​ The repair of an inguinal hernia , also known as herniorrhaphy or hernioplasty, is a common surgical procedure. There are two primary types of surgery used to repair inguinal hernias: open surgery and laparoscopic surgery. ​ Open Inguinal Hernia Repair (Herniorrhaphy) : Anesthesia: The patient is given general, spinal, or local anesthesia. Incision: The surgeon makes an incision in the groin area, where the hernia is located. Hernia Repair: The protruding tissue is pushed back into the abdomen, and the weakened area (the hernia sac) is sewn shut. Reinforcement: Often, the weakened area is reinforced with a synthetic mesh or screen to provide additional support. This is called hernioplasty. Closure: The incision is then closed with sutures, staples, or surgical glue. ​ Laparoscopic Inguinal Hernia Repair: Anesthesia: This procedure is typically done under general anesthesia. Incisions: The surgeon makes several small incisions in the lower abdomen and inflates the abdomen with a harmless gas (carbon dioxide), which helps the surgeon see the abdominal organs more clearly. Laparoscope Insertion: A thin tube with a tiny camera (laparoscope) is inserted into one incision. Hernia Repair: Instruments are inserted in other incisions to repair the hernia. As with open hernia repair, a mesh may be used to reinforce the area. Closure: The incisions are closed with sutures, staples, or surgical glue. ​ Anesthetic Implications for Inguinal Hernia Repair ​ Anesthesia type: General, local anesthesia, neuraxial ​ Airway: ETT ​​ Preoperative: ​ ​ A strangulated bowel in the hernia will require an emergency laparotomy and a bowel resection A spinal block to the T6 level may be done 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: ​ ​ Traction on the viscera can cause vagal stimulation and bradycardia Duration: 1-2 hours Position; Supine, one arm tucked to the side or arms tucked ​ Postoperative: ​ Pain management PONV prophylaxis Avoid coughing and straining on emergence ​ Complications: ​ Urinary retention Infection Hernia recurrence Nerve damage Hemorrhage Organ damage Subcutaneous emphysema from pneumoperitoneum Bowel obstruction Bladder injury Postoperative ileus seroma ​ 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 Laparoscopic Inguinal Hernia Repair Columbia University Right Inguinal Hernia Repair California Hernia Specialists Laparoscopic Inguinal Hernia Repair

PACEMAKER AND AICD INSERTION ​ ​ A pacemaker and an Automated Implantable Cardioverter Defibrillator (AICD) are two types of cardiac devices used to manage heart rhythm disorders. ​ Pacemaker: A pacemaker is a small device that's placed in the chest to help control abnormal heart rhythms. It uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are typically used to treat bradycardia (slow heart rate). The device consists of a battery, a computerized generator, and wires with sensors at their tips. These wires are inserted into a vein under the collarbone and guided to the heart, where they're permanently anchored. Automated Implantable Cardioverter Defibrillator (AICD): An AICD is similar to a pacemaker but has additional capabilities. It's used in people who are at risk of life-threatening arrhythmias like ventricular tachycardia or ventricular fibrillation. Besides functioning as a regular pacemaker, an AICD can deliver shocks to the heart if it detects a dangerous rhythm. It helps in restoring the normal heart rhythm and is a form of treatment and prevention for cardiac arrest. ​ ​ Factors that may alter the threshold of cardiac pacemakers: Hyperkalemia Hypokalemia Arterial hypoxemia Myocardial Infarction Catecholamines ​ Anesthetic Implications for Pacemaker and AICD Insertion ​ Anesthesia type: S edation with a local anesthetic. Provider and surgeon preference ​ Airway: LMA or ETT may be needed ​​ Preoperative: ​ ​ Patients may have decreased cardiac reserve, coronary artery disease, ventricular dysfunction, cardiomyopathy, and valvular heart disease Fluoroscopy will be used The pacemaker ensures that the heartbeat will not go lower than a preset level Transcutaneous pacing pads should be placed on patient External defibrillator monitor on and ready for use Have chronotropic drugs available (atropine, epinephrine, isoproterenol) Avoid the use of negative inotropes ​ Intraoperative: ​ ​ Supine position with head turned away from operative side The proceduralist will infiltrate the skin with local anesthetic Carefully monitor the EKG for sustained cardiac dysrhythmias Tunneling part of the procedure is stimulating When there is a concern for the subclavian/innominate vein patency, a venogram may be performed If AICD, the cardiologist will indice V-tach or V-fib (deepen sedation prior to defibrillation) EBL minimal ​ Postoperative: ​ Cardiac rate and rhythm should be continuously monitored Have backup pacing capability ​ Complications: ​ Pneumothorax Pericarditis Heart muscle perforation Embolism Bleeding Vascular injury Pericardial effusion Cardiac tamponade Lead dislodgement Cardiac arrest ​ ​ 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 Ninja Nerd Nursing Pacemakers Asia Pacific Heart Rhythm Society Permanent Pacemaker Implantation Tutorial Strong Medicine ICDs and Biventricular Pacemakers

DILATION AND CURETTAGE (D&C) ​ Dilation and Curettage (D&C) is a common gynecological procedure that involves dilating the cervix to access and scrape the lining of the uterus. ​ Here's a more detailed description of the procedure: Dilation: This step involves gradually opening the cervix, which is the lower part of the uterus that leads into the vagina. This is usually accomplished with the use of a series of gradually larger dilators. Curettage: After dilation, a tool called a curette is inserted into the uterus. This tool can be either sharp, having a knife-like edge, or blunt. It is used to scrape or suction the lining of the uterus (endometrium). The collected tissue can then be sent for laboratory analysis if needed. ​ D&C can serve several purposes. It is often used to diagnose or treat abnormal uterine bleeding. The tissue collected during a D&C can be examined for causes of bleeding such as polyps, endometrial hyperplasia, or uterine cancer. It's also commonly used to clear the uterus after a miscarriage, abortion, or to remove molar pregnancies. ​ Dilation, Suction, and Curettage (D&C) is a procedure that is used in various circumstances, such as in the management of miscarriages, to treat heavy menstrual bleeding, or to obtain samples of tissue for further testing. ​ Anesthetic Implications for Dilation and Curettage (D&C) ​ Anesthesia type: General, MAC, neuraxial, or regional ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Full stomach precautions for pregnant patients more than 16 weeks Anxiolysis for emotional distress Consider having Oxytocin (Pitocin), Methylergonovine (Methergine), and/or Carboprost (Hemabate) available ​ Intraoperative: ​ ​ Anticipate a vasovagal response with traction on the uterus (bradycardia and decreased cardiac output) The further along the pregnancy, the greater the possibility of blood loss Dilation of the cervix is very stimulating May encounter hemodynamic instability due to uterine bleeding Possibility of sepsis from retained products of conception Position: Lithotomy (slight trendelenburg) Duration 5-20 minutes ​ Postoperative: ​ PONV prophylaxis Pain management ​ Complications: ​ Uterine perforation Bleeding Cervical laceration Infection Peroneal nerve injury Vasovagal response ​ 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 Dilation and Curettage (D & C) Novice Anaesthesia Post Operative Nausea and Vomiting (PONV)

SEPTOPLASTY AND RHINOPLASTY Septoplasty is a surgical procedure designed to correct a deviated septum. The septum is the wall of bone and cartilage that divides your nostrils. When it's deviated, it can make one nasal passage smaller than the other, which can lead to problems with proper breathing. ​ During septoplasty, the surgeon works through the nostrils to reshape the septum, aiming to improve airflow and correct any obstructions. It's generally an outpatient procedure, meaning you can go home the same day. ​ The procedure is typically recommended for individuals who have a significantly deviated septum causing health issues like chronic sinusitis, nosebleeds, facial pain, difficulty in breathing, or snoring. It's not usually performed for cosmetic reasons but primarily for functional improvement. ​ Rhinoplasty , commonly referred to as a "nose job," is a surgical procedure that changes the shape of the nose. This surgery can be performed for various reasons, including altering the appearance of the nose, improving breathing, or both. ​ The specific changes made during a rhinoplasty can include altering the size of the nose, reshaping the tip, narrowing the nostrils, and changing the angle between the nose and the upper lip. It's important to have realistic expectations and to discuss these with a qualified plastic surgeon before deciding to undergo the procedure. ​ The surgery can be done using a closed procedure, where incisions are hidden inside the nose, or an open procedure, where an incision is made across the columella, the narrow strip of tissue that separates the nostrils. Through these incisions, the skin covering the nasal bones and cartilage is gently raised, allowing access to reshape the structure of the nose. Anesthetic Implications for Septoplasty or Rhinoplasty ​ Anesthesia type: General, TIVA ​ Airway: ETT , Oral RAE ​​ Preoperative: ​ ​ Rhinoplasty is the surgical correction of the external appearance of the nose Septoplasty provides surgical correction of any deformity of the nasal septum The surgeon may prefer an oral RAE tube (keeps ETT out of surgical area) or reinforced type ETTs ETT tube may be taped to the mandible in the midline position Local anesthetic (cocaine, lidocaine or epinephrine) are placed in nares to decrease mucosal swelling and minimize bleeding The sphenopalatine and anterior ethmoidal nerves provide sensation to the nasal septum and lateral walls Special care must be taken to tape the patient’s eyes Mild controlled hypotension may be requested to facilitate hemostasis A throat pack is usually placed (prevents blood from entering the posterior pharynx Decongestant nasal spray may be administered ​​ Intraoperative: ​ Intranasal packing is inserted, and a plastic splint is placed A mustache dressing may be placed under the nares Position: Supine, reverse Trendelenburg, arms tucked, table turned 90-180 degrees Intraop administration of decadron (8–12 mg iv) to minimize postop edema ​ Postoperative: ​ Before extubation, gently suction the patient’s throat with soft suction Make sure throat pack is removed No pressure should be placed on the nose Avoid coughing, bucking, or straining Smooth emergence High risk of PONV ​​ Complications: ​ Bleeding Laryngospasm Aspiration of gastric contents or bloody Local anesthetic complications (HTN, dysrhythmias, seizures) Dysrhythmias Tachycardia ​ ​ 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 Now Trending Rhinoplasty (Nose Job) Olympus Medical Systems 4K Endoscopic Septoplasty University of Kentucky ENT Anesthesia

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) Transesophageal Echocardiography (TEE) is an advanced form of echocardiography, which is a diagnostic test used to visualize the heart and its functioning. Unlike standard echocardiography, which is performed externally by placing an ultrasound probe on the chest, TEE involves the insertion of a specialized probe into the esophagus. This approach offers a closer and more detailed view of the heart, as the esophagus is located directly behind the heart. ​ Here are some key points about TEE: Procedure: During a TEE, the patient is usually given a sedative and a local anesthetic to numb the throat. A flexible probe with an ultrasound device at its tip is then gently guided down the throat into the esophagus. The probe emits sound waves that create detailed images of the heart's structure and function. Uses: TEE is particularly useful for assessing certain heart conditions more accurately than standard echocardiography. These include problems with the heart valves, detection of blood clots or masses inside the heart, assessment of the severity of certain heart diseases, and evaluation of the heart's function in patients with a thick chest wall or lung diseases. Advantages: The primary advantage of TEE over traditional echocardiography is its ability to produce clearer, more detailed images of the heart. This is because the ultrasound waves don't have to pass through skin, bones, or other tissues, which can obscure the view in standard echocardiography. ​ TEE is an invaluable tool in cardiology, offering critical insights into heart health, particularly in complex cases where other diagnostic methods might not provide sufficient detail. Anesthetic Implications for Transesophageal Echocardiography (TEE) ​ Anesthesia type: MAC, TIVA ​ Airway: Natural airway ​​ Preoperative: ​ ​ TEE provides beat to beat cardiac assessment Lidocaine 4% spray into the back of oropharynx may be administered (gargle for 10 seconds) Patients may have poor cardiac function Have cardiac meds and emergency airway available Assess reason for TEE and ejection fraction (EF) Patients may haver atrial fibrillation and cardiologist want to check for thrombi The left atrial appendage is the most common place for clot formation Assess for history of esophageal varices (may cause bleeding) Ketamine is adventitious in patients with critically low ejection fraction Dentures must be removed Bite block is placed for TEE probe before induction Chin lift and jaw thrust facilitates the insertion of TEE probe (this is the most stimulating part) ​​ Intraoperative: ​ Hypoventilation can worsen right heart function If the patient obstructs, manipulate airway (chin lift, jaw thrust) to ventilate ​ Postoperative: ​ Wait for patient to follow commands and open his/her mouth before removing bite block device ​​ Complications: ​ Throat irritation Esophageal injury/perforation Pharyngeal or laryngeal trauma Teeth damage Hypotension Cardiac arrest Submucosal hematoma ​ ​ 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. ​ ​ ​ ​ ​​ ​​

BREAST LUMPECTOMY ​ A breast lumpectomy, also known as breast-conserving surgery or partial mastectomy, is a surgical procedure to remove a cancerous tumor or an area of abnormal tissue from the breast, while preserving as much of the healthy breast tissue as possible. The goal of this surgery is to treat breast cancer while maintaining the natural shape and appearance of the breast. ​ It involves the excision of a breast tumor with appropriate tumor-free margins. ​ This procedure may be performed in combination with an axillary node dissection. ​ A lumpectomy is typically recommended for patients with early-stage breast cancer when the tumor is small and has not spread to other body parts. The procedure is often followed by radiation therapy to kill any remaining cancer cells and reduce the risk of cancer recurrence. ​ Breast reconstruction is an option for most women undergoing mastectomy. ​ The recovery time for a breast lumpectomy varies depending on the individual and the extent of the surgery. Most patients can go home the same day or the day after the surgery. ​ Lumpectomy (also called breast-conserving surgery, partial mastectomy or wide excision) ​ Anesthetic Implications for Breast Lumpectomy ​ Anesthesia type: General, regional anesthesia, IV sedation/ local anesthesia ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Doxorubicin chemotherapy can cause cardiomyopathies Check for anemia and thrombocytopenia after chemotherapy The blood pressure cuff and the peripheral IV should be placed on the nonoperative-side arm May be performed with wire localization, where a radiologist inserts the tip of a wire into the target tissue under fluoroscopic guidance preoperatively Placed EKG leads away from the sterile field Patient anxiety associated with breast cancer and altered body image Larger tumors, lymph node involvement, and the lack of estrogen and progesterone receptors are associated with worse prognosis ​ Intraoperative: ​ Avoid muscle relaxants for axillary dissection and surgical identification of nerves Regional anesthesia: A block from T1-T6 is required Position: Supine with the ipsilateral arm abducted Avoid brachial plexus stretch Surgical time 15-60 minutes EBL minimal ​ Postoperative: ​ Pain management PONV prophylaxis ​ Complications: ​ PONV Lymphedema Seroma Infection Pneumothorax Hematoma Injury to axillary neurovascular structures Psychological trauma Venous thromboembolism ​ 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 AllHealthGo Lumpectomy Surgery Procedure Ventura Surgery School Lumpectomy for breast cancer Dirty Medicine Breast Pathology