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FLS Modules Revised Study Guide
1. Laproscopic instruments diameter and length ranges: 2-10mm, 30-45cm
2. hopkins rod lens: light has to travel back through the rod to capture the image.
3. decreasing light in the camera for...: decreasing diameter, increasing scope angle (ie 5mm and 30 degree has less light
than 10mm 0 degree)
4. When is zero degree scope most useful: when working in a small area directly in line with the scope and ports, like the
pelvis
5. how to check fiber optics light connection: black dots= broken fibers
6. why does it fog up?: temperature and humidity discrepancy between the OR and body
7. tools for defogging: FRED antifog (must dry before putting back in), put laparoscope in hot water
8. methods to clean a smudged lens: gently wipe on clean tissue (liver, uterus, bowel), remove scope and clean with hot water and
gauze
9. Insufflation gas type and reasoning: CO2- readily available, inexpensive, non combustable, warmed and humidified
better
10. high flow insufflation: 10 or more L per minute
11. preventing loss of pneumo with suctioning: keep suction tip below the fluid level
12. most common light source: 300W xenon lamp
13. Troubleshooting steps: gas preOP: 1. check that co2 tank is full
2. check co2 tank gasket is secured
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3. check that spare co2 tank is available in the OR
14. troubleshooting steps: image: 1. check that the monitor is plugged in and turned on 2. check that all cables are
connected securely
15. troubleshooting steps: loss of working space: insufflator settings: mea- sured pressure
is the same or higher than the preset pressure: 1. the patient may not be adequately relaxed or there is a mechanical block of gas flow
2. inspect abdomen for rhythmic muscle contraction and palpate the abdomen for firmness
3. check port valves to make sure they are open
4. check for kinks in tubing and make sure no one is standing on them
16. troubleshooting steps: loss of working space: insufflator settings: low pres- sure and high
flow rate: 1. there is a leak in the insufflation circuit
2. check that the tubing has not become disconnected from insufflator or port
3. check that all valves are closed
4. check all port sites for leaking co
5. check for foley catheter bag distention or bowel distention
17. troubleshooting steps: loss of working space: insufflator settings: low pres- sure and no flow:
- make sure that the insufflator power is on
- check gas level in the tank
18. troubleshooting steps: loss of working space: complete loss of operative image: 1. check for
disconnected power cords, video cables
4 / 18 electrode through its insulation to a passive electrode. active electrode (such as monopolar hook) can give a charge if it touches a grasper or camera briefly, they store energy, then they contact tissue and injure it
27. bipolar definition: tissue is placed between two electrodes. current flows only through the tissue contiguous with both
electrodes. lower energy requirement, less lateral tissue damage. Can seal vessels up to 7mm
28. bipolar energy delivery: computer measures tissue impedance of grasped tissue--.controlled energy delivery-->
denaturation of collagen-->creation of permanent seal
29. bipolar hazards: inadvertent thermal injury: avoid activating the device in close proximity to adjacent organs
30. bipolar hazards: inadvertent cutting of vessels before adequate sealing: -
make sure to complete entire activation cycle prior to cutting
31. bipolar hazards: improper functioning if metal is within the jaws: including clips or staples
32. ultrasonic dissection: mechanical energy converted to high frequency ultrasonic vibration
33. ultrasonic shears: consist of vibrating jaw or blade and a passive jaw. the passive jaw acts as a backstop to trap tissue
against the active blade. active blade is unprotected and can damage tissue during or after use
34. warfarin discontinue time: 3 days
35. important history to consider preOP (5): 1. history of DVT/PE
2. hx radiation
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3. hx hip prosthetics
4. sig cardiopulmonary conditions (important to continue throughout preoperative period)
5. need for stress dose steroids
36. NSAIDs including ASA: do not need to be discontinued
37. ASA level not appropriate for lap surgery: 4-5, might not be able to tolerate pneumoperi- toneum due to
decreased venous return and need for hyperventilation
38. obese patients: trocar insertion: use of longer trocars (up to 100mm)
39. thin patients: trocar insertion: 1. elevate abdomen
2. consider placing veress needle away from the midline near the costal margin
3. consider utilizing open approach or visiport for direct visualization
40. contraindications to laparoscopy: absolute (4): 1. inability to tolerate laparotomy
2. hypovolemic shock
3. lack of proper surgical training
4. lack of appropriate institutional support
41. contraindications to laparoscopy: relative (5): 1. inability to tolerate general anesthesia
2. long standing peritonitis (can increase risk of injury on trocar insertion)
3. large abdominal or pelvic mass
4. massive incarcerated ventral and inguinal hernias (can have loss or peritoneal space)
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44. lap colon resection relative contraindications (4): 1. large fixed mass
2. dense pelvic adhesions
3. massive bowel dilation
4. t4 tumors
45. lap appendectomy relative contraindications (2): 1. phlegmon
- large abscess
46. emergency laparoscopy relative contraindications (3): 1. longstanding peritonitis
2. hemodynamic instability paritally correctable with resuscitation
3. massive bowel dilation
47. pelvic laparoscopy relative contraindications (2): 1. large fixed mass
- inability to tolerate trendelenberg
48. lap foregut procedures relative contraindications (2): 1. previous gastric operation at GE juntion
- hepatosplenomegaly
49. lap antireflux surgery relative contraindications (5): 1. esophogeal shortening
2. epithelial dysplasia
3. previous gastric surgery at GE junction
4. liver enlargement
5. large hiatal hernia
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50. lap hernia repair relative contraindications (4): 1. large, chronically incarcerated hernia
2. acutely incarcerated hernia
3. need for removal of large prosthetics
4. ned for skin graft removal o large scar revision
51. things that are NOT contraindications (commonly mistaken) (9): 1. diaphragm injury
2. GI bleed
3. perforated viscus
4. bowel obstruction
5. abdominal trauma
6. IUP or ectopic preg
7. obesity
8. COPD
9. renal insuflciency
52. precautions in pregnancy: 1. tailoring initial access based on fundal height
2. L lateral position
3. lowering insufflation pressures
4. FHT pre- and post-op
53. lap SBO precautions: need to use a direct visualization entry
10 / 18 from prior open operation
- through previously placed intraperitoneal mesh for hernia repair
65. complications of veress needle insertion (8): 1. bowel injury
2. mesenteric or omental vascular injury
3. retroperitoneal vascular injury
4. cardiac arrhythmia
5. hypotension
6. high airway pressures
7. pneumothorax
8. gas embolism
66. hasson technique: 1. 2 cm skin incision
2. carried down through the skin and subQ
3. expose fascia
4. incise fascia with scalpel or bovie
5. place anchoring sutures in fascia while well exposed
6. dissect through pre-peritoneal fat and identify peritoneum
7. grasp peritoneum , elevate, incise
8. blunt tip trochar is inserted under direct visualization and secured to the fascia with the stay sutures
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67. things to monitor with co2 pneumoperitoneum (6): 1. cardiac rhythm
2. pulse ox
3. end tidal co
4. heart rate
5. BP
6. urine output
68. CO2 chemical effects: 1. increases arterial co2 concentration--> drop in serum pH
- increases end tidal co2 (greatest change In the first 20 minutes)
69. pulmonary physiology with co2 pneumo: 1. increased minute ventilation to eliminate ab- sorbed CO
2. reduced functional residual capacity (because of increased intra-abdominal pressure)
3. increased peak airway pressure
4. reduced pulmonary compliance
70. overview of cardiovascular effects of co2 pneumo: 1. systemic vascular changes
2. cerebral auto regulation of blood flow
3. vagal responsiveness to reverse trendenenberg
4. increased venous stasis because of pressure in peritoneum (need for use of VTE ppx)
71. Alternative gases: NO: benefits: less acid-base disturbance, increased patient tolerability in patients with severe cardio
pulmonary disease, less post op pain
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3. post-op oliguria should resolve within a few hours
4. don't fluid overload--> CHF
78. hypothermia related to pneumo: use humidified and warmed gas, warm IVF, bear hugger, warm irrigation, warm air
temp
79. extraperitoneal gas extravasation can cause (4): 1. subcutaneous gas
2. thoracic gas
3. delayed co2 toxicity
4. gas embolus
80. gas embolus: - occurs in less than 1% of cases
- diagnosis: sudden CV collapse due to impaired venous return to the heart. JVD, hypotension, tachycardia, mill wheel murmur -treatment: cessation of insufflation, fluid administration, trendelenberg with L side down position prevent embolus from traveling, central line into Right heart to break up embolus
81. most common sources of unrecognized bleeding (3): 1. trocar injury to abdominal wall vessels
2. injury to vessels or organs away from the operative field
3. tamponade of venous bleeding by pnuemo
82. First lap appy: 1980 by Semm (GYN Doc)
83. First lap chole: Eric muhe 1985
84. visualizing liver: use angled scope, look for macronodularity associated with cirrhosis, can use ultrasound
85. anterior abdominal wall dx lap: to look for post op bleeding, adhesions, hernia or tumor. use angled scope.
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86. dx lap for suspected appy: tuck left or both arms, surgeon and assisteant to both stand on left. trendelenberg with
left tilt
87. examining the small bowel: two monitors, one at head and one at feet. (left shoulder and right hip). ports all on L
side of abdomen. systematic examination of the bowel from one end to the next. use graspers for atraumatic handling. handle mesenteric fat as opposed to bowel wall. start at ileocecal valve for SBO
88. exposure of retroperitoneal structures: - spleen, kidneys, adrenals
- lateral or semilateral positioning for structures above iliac bifurcation
- below bifurcation of iliac can be dorsal supine
89. diag lap for trauma: - should be hemodynamically stable
- arms tucked
- angled scope
- monitor on each side
90. biopsy methods and what to avoid: 1. peritoneal washings
2. FNA
3. Core needle
4. incisional (wedge)
5. excisional
avoid electrocautery
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5. topical hemostatic agents
6. sutures
101. benefits of braided suture: easier to handle, lack elastic memory, don't fray
102. dyed sutures preferred because?: don't blend in with blood
103. intracorporeal knot tying ergonomics: elbows flexed at 90 degrees and ports at least 10cm apart
104. interrupted vs continuous sutures: 1. interrupted less cumbersome but each requires a knot
- continuous needs constant tension (done with assistant's help and/or intermittently locking the throws)
105. extracorporeal knot length: 30 inches or 75cm
106. minimize tissue friction extracorporeal knot: use instrument as a fulcrum, because of the 180 degree angle
107. roedner's knot: tied completely exrtraporporeally then pushed down. used for: blood vessels, appendix, fallopian tube, cut end
of cystic duct
108. linear staplers: 2-3 rows of staples on either side of knife blade require 12
mm port generally
109. choice of staple height: 1. vascular: 2-2.5mm
2. GI tract 3-3.5 mm
3. distal stomach or thickened GI tract 4-4.5 mm
110. removing ports under direct lap visualization because:: bleeding may not be evident during procedure,
and may not be evident externally after port is removed.
111. when to use monopolar for hemostasis: small vessels, slow rate of bleeding, need a relatively dry operative field
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112. when to use bipolar for hemostasis: larger vessels, works in wet operative field, less lateral thermal spread, lower
energy requirement
113. risk factors for PONV (8): 1. female
2. young
3. history of PONV
4. motion sicknress
5. non smokers
6. use of NO or volatile anesthetics
7. opiods
8. longer procedure length
114. prevention of PONV: 1. use 5HT3 receptor antagnists and h1 receptor antagonists
2. limit opiods
3. local and regional anesthetic if poss
4. avoid NO
115. shoulder pain: lasts 1-3 days
treat the same as incisional pain
116. post op injuries that occur later (4): 1. partial thickness injruies
2. non visualized electrosurgical burn
