WikiAnesthesia - User contributions [en]

Nephrectomy

2025-09-25T23:17:45Z

Dominicmangino:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Two large bore PIV, usually with a-line
| monitors = Standard, +/- A-line
| considerations_preoperative = 2u pRBC on standby, usually EKG, CBC, CMP
| considerations_intraoperative = Avoid nitrous (bowel expansion), avoid extremities with AV fistula, and avoid forearm veins for patients who may need future dialysis, avoid potassium containing fluids in patients with impaired renal function
| considerations_postoperative = hemorrhage, urinary fistula, UTI, DVT, wound infection, pleural effusion
}}

There are three categories for nephrectomies, depending on the extent of surgical involvement, these include: simple, partial, and radical nephrectomy.

A '''simple nephrectomy''' refers to the surgical removal of the affected kidney and small segment of the proximal ureter. Diagnoses warranting this procedure can include benign conditions, such as: hematuria, recurrent urinary tract infections, nephrolithiasis, hydronephrosis, flank pain, or kidney donation<ref>{{Cite web|title=Nephrectomy|url=https://www.nephrologyspecialistsoftulsa.com/nephrectomy.php|access-date=2022-02-02|website=www.nephrologyspecialistsoftulsa.com}}</ref><ref>{{Cite web|title=Simple Nephrectomy|url=http://urology-textbook.com/simple-nephrectomy.html|access-date=2022-02-02|website=urology-textbook.com}}</ref>.

A '''partial nephrectomy''' refers to the surgical removal of the pathologic portion of the kidney. Diagnoses warranting this procedure can include: chronic hydronephrosis, hypoplastic kidney, renovascular hypertension, or a double collecting system<ref name=":0">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>.

A '''radical nephrectomy''' refers to the surgical removal of the affected kidney, with surrounding perinephric fat, Gerota's fascia, proximal 2/3 of the ureter, and can additionally include paracaval or para-aortic lymphadenectomy<ref name=":0" />. Diagnoses warranting this procedure are usually renal cell carcinoma or a double collecting system. Of note, if there is tumor or thrombus involving the vena cava or right atrium an interprofessional team involving cardiac surgery may also be involved.

== Preoperative management==

=== Patient evaluation===
{| class="wikitable"
|+
!System
! Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|Renal hypertension, assess for IVC thrombus,
|-
|Pulmonary
|Possible pulmonary mets if RCC
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|often CKD present
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===
Electrolytes, BUN, Cr. If indicated, perform additional workup for cardiac and pulmonary disease

===Operating room setup===

===Patient preparation and premedication===

===Regional and neuraxial techniques===

==Intraoperative management ==

===Monitoring and access===

* Standard monitoring
*2 large bore IVs
* Arterial line
* Consider central line if IVC or RA thrombus

===Induction and airway management===

* Standard induction

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==

===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Simple
!Open Radical
|-
|Unique considerations
|
|
|-
|Position
|Flank or prone
|Flank vs prone
|-
|Surgical time
|
|
|-
|EBL
|500
|500
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]
<references />

Upper GI endoscopy

2025-09-14T18:50:43Z

Dominicmangino:

{{Infobox surgical procedure
| anesthesia_type = MAC vs. GA
| airway = Natural airway w/ bite block
| lines_access = 1 PIV
| monitors = Standard ASA
| considerations_preoperative = GERD, unstable airway from upper GI bleed
| considerations_intraoperative = Aspiration risk
| considerations_postoperative =
}}

An '''upper GI endoscopy''' (or '''EGD''') is a procedure where a flexible scope is inserted through the mouth to diagnose and treat problems with the upper GI tract (esophagus, stomach, duodenum). It is commonly used to further work up patients with:

* upper GI bleed
* severe GERD
* dysphagia
* intractable vomiting
* non-cardiac chest/abdominal pain
* unexplained weight loss

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Especially important to assess risk of patient obstructing upon induction when GA with natural airway or MAC is the anesthetic plan.
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Review risk factors for OSA i.e STOP BANG
|-
|Gastrointestinal
|
|-
|Hematologic
|Patients may be acutely anemic from upper gi bleed, assess appropriateness of transfusing PRBC prior to procedure
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
Preoperative Hgb for patients with severe bleeding.

=== Operating room setup ===

* Nasal cannula/POM mask
*Bite Block
* Propofol drip
*Prepare to manage airway if severe hypoxemia develop, with ability to provide positive pressure ventilation with 100% oxygen.
*Succinylcholine for treatment of laryngospasm

===Patient preparation and premedication===
Consider using an antisialagogue such as glycopyrrolate for patients considered high risk for increased secretions.

=== Regional and neuraxial techniques===
N/A

==Intraoperative management==

===Monitoring and access===

* Standard ASA monitors
*1 PIV

===Induction and airway management===
GA w/ natural airway vs MAC sedation. The insertion of the scope itself can be quite stimulating, and many patients may not be able to tolerate this with MAC sedation. Use nasal cannula, or POM mask for oxygenation. Nasal CPAP or High flow oxygen may be appropriate for patients at high risk of obstructing and becoming hypoxemic.

For patients with severe upper GI bleed or severe GERD who are at risk of aspiration, consider RSI with ETT to secure airway.

===Positioning===
Generally left lateral decubitus

===Maintenance and surgical considerations===

*Propofol drip
*Intermittent boluses of propofol may be used in shorter duration cases
*A fentanyl push prior to scope insertion (25 mcg) can help minimize coughing
*The patient being able to tolerate a jaw thrust prior to scope insertion can help determine if patient is deep enough if procedure done under MAC

===Emergence===

==Postoperative management==

=== Disposition===
To PACU and generally safe discharge to home/floor within hours.

===Pain management===
Minimal pain

===Potential complications===
Patients can be high aspiration risk if there is severe upper GI bleed or severe GERD.

Hypoxemia

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Pancreaticoduodenectomy

2025-09-14T18:48:21Z

Dominicmangino:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore IV
Arterial line
± Central line
| monitors = Standard
5-lead ECG
ABP
± CVP
| considerations_preoperative = Mechanical bowel prep
ERAS
| considerations_intraoperative = Combined general ± epidural
Goal-directed fluid therapy
Glucose control
Blood transfusion management
Lung protective ventilation
Avoid hypothermia
| considerations_postoperative = PONV
ERAS
Goal-directed fluid therapy
Early NG, foley, and drain removal
Early PO nutrition
Glycemic control
Non-opioid analgesia
DVT prophylaxis
Pulmonary rehabiliation
Early ambulation
}}

A '''pancreaticoduodenectomy''' (also known as a '''Whipple Procedure''' after Dr. Allen Whipple) is the most commonly performed surgery to remove pancreatic tumors, and is typically done for patients who have tumors located in the head of the pancreas or adjacent regions. The procedure is anatomically complicated, and there may be anatomical variations among the various involved blood vessels and ducts in the area. Even after pancreatic resection, the 5-year survival rate is only 15-20% (compared with 5% without surgery).

A standard whipple consists of resection of head of pancreas, gallbladder, part of duodenum, pylorus of the stomach, and lymph nodes near the pancreatic head. The surgeon reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the SI during digestion. Pyloric-sparing whipples are a variant of this procedure.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Many pancreatic cancer patients have been heavy smokers, increased risk of pulmonary complications
|-
|Gastrointestinal
|Check if patient has had a bowel prep, they may be dry, assess for obstruction or signs of full stomach
|-
|Hematologic
|Assess for anticoagulation and possible contraindications to an epidural. DVTs/PEs are major common complications of pancreatic cancer patients
|-
|Renal
|
|-
|Endocrine
|80% have either diabetes or impaired glucose tolerance. Diabetics are at increased risk of MI, CVA, renal infarction
|-
|Other
|Pancreatitis patients tend to be hypotensive and hypovolemic
More than 80% of pancreatic cancers are diagnosed in patients >65y/o with comorbidities.
|}

=== Labs and studies ===

* CBC, BMP, LFTs, coags
* EKG in any patient with risk factors for CAD
*Type and Screen, have 2 units of pRBC on hold
*consider intraoperative labs every 1-2 hours for acid/base, sugars, Hgb (if bleeding concerns),

=== Operating room setup ===

* A-line setup
* Have insulin available in the room

=== Patient preparation and premedication ===

* Many are ERAS pathway
*Strongly consider acetaminophen, gabapentin, celecoxib, particularly if epidural is not used

=== Regional and neuraxial techniques ===

* Preoperative epidural placement is common
*TAP block can be administered if there is no epidural placement

== Intraoperative management ==

=== Monitoring and access ===

* A-line, 2 large-bore PIVs
* CVP is not as common anymore
* NG tube should be placed and taped for postop

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

* Regular glucose checks and insulin infusion titration should occur throughout the procedure
*Consider epidural maintainance for intraop pain if BP tolerates (e.g. bupivacaine 0.125% 5-10 mL/hr)
*Consider ketamine bolus (0.5 mg/kg) and infusion (0.2-0.3 mg/kg/hr), especially if epidural is not used

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* ICU

=== Pain management ===

* Epidural can be used for postoperative pain management

=== Potential complications ===

* Pulmonary complications occur following pancreatic resections in 25% of patients. Pulmonary recruitment is important with upper abdominal surgery
** Pneumonia
** Failure to wean from ventilator
** Post-extubation respiratory failure represents mortality rate of 1-5%
** Patients with pulmonary disease account for 40% of postoperative complications and 20% of deaths
* Delayed gastric emptying: Usually at 7-10 days the stomach begins to recover function
* Pancreatic fistula
* Bowel leakage from anastomosis
* Hemorrhage
* Abscess
* Pancreatogenic diabetes: Following pancreatic resection, insulin receptors are peripherally upregulated and patients are more sensitive to insulin. Patient is more prone to large swings in glucose.

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Standard Whipple
!Pylorus Preserving Whipple
|-
|Procedure
|Pylorus resected
|The pylorus is not resected
|-
|Position
|
|
|-
|Surgical time
|4-7h
|4-7h
|-
|EBL
|200-800cc
|200-800cc
|-
|Postoperative disposition
|ICU
|ICU
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Pancreatic surgery]]

Ventriculoperitoneal shunt

2025-09-14T18:46:58Z

Dominicmangino:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
| monitors = Standard
ECG leads on back/side
| considerations_preoperative =
| considerations_intraoperative = ICP management
High stimulation during tunneling
| considerations_postoperative =
}}

VP shunting is commonly utilized to tread hydrocephalus. A thin catheter is inserted into the brain to shunt CSF from the lateral ventricles of the brain into the peritoneum. The surgeon usually makes incision in the right parietal area (behind the right ear) as well as in the abdominal wall via the rectus sheath to access the peritoneum. The distal catheter is then tunneled from under the skin and subcutaneous tissue behind the ear, neck, down to the peritoneal cavity. A fluid pump with valve is placed under the skin behind the ear, and the valve is connected to both catheters. When extra intracranial pressure builds, the valve opens and excess fluid can drain out into the peritoneal space.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|Check for antiepileptics, as they alter metabolism of other anesthetic drugs
Assess for kyphoscoliosis
|-
|Cardiovascular
|Assess for congenital cardiac disease
|-
|Pulmonary
|Assess for congenital bronchopulmonary dysplasia or recurrent respiratory infections secondary to neurologic dysfunction
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|Patients are most commonly children
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Usually 20G PIV is sufficient
* EKG leads should be placed on the back and side as the chest is prepped for tunneling

=== Induction and airway management ===

=== Positioning ===

* Supine, arms to the side, head turned to the left (contralateral side of shunt insertion)
* Shoulder roll occasionally utilized

=== Maintenance and surgical considerations ===

* Duration 1-2h
*Tunneling is the most stimulating portion of the surgery
*Mild hyperventilation can be employed if elevated ICP is involved, but avoid overventilation as ventricles can be more challenging to cannulate if empty due to hyperventilation

=== Emergence ===
Emergence should be timely and avoid medications that alter neuro exam.

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

* Head bleed
* Brain swelling
* Bowel perforation
* CSF fluid leakage under the skin
* Infection of the shunt or brain
* Seizure
* Damage to brain tissue
* Shunt malfunction requiring surgical repair

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Pancreaticoduodenectomy

2025-09-14T18:40:43Z

Dominicmangino: added intraoperative labs considerations

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore IV
Arterial line
± Central line
| monitors = Standard
5-lead ECG
ABP
± CVP
| considerations_preoperative = Mechanical bowel prep
ERAS
| considerations_intraoperative = Combined general ± epidural
Goal-directed fluid therapy
Glucose control
Blood transfusion management
Lung protective ventilation
Avoid hypothermia
| considerations_postoperative = PONV
ERAS
Goal-directed fluid therapy
Early NG, foley, and drain removal
Early PO nutrition
Glycemic control
Non-opioid analgesia
DVT prophylaxis
Pulmonary rehabiliation
Early ambulation
}}

A '''pancreaticoduodenectomy''' (also known as a '''Whipple Procedure''' after Dr. Allen Whipple) is the most commonly performed surgery to remove pancreatic tumors, and is typically done for patients who have tumors located in the head of the pancreas or adjacent regions. The procedure is anatomically complicated, and there may be anatomical variations among the various involved blood vessels and ducts in the area. Even after pancreatic resection, the 5-year survival rate is only 15-20% (compared with 5% without surgery).

A standard whipple consists of resection of head of pancreas, gallbladder, part of duodenum, pylorus of the stomach, and lymph nodes near the pancreatic head. The surgeon reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the SI during digestion. Pyloric-sparing whipples are a variant of this procedure.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Many pancreatic cancer patients have been heavy smokers, increased risk of pulmonary complications
|-
|Gastrointestinal
|Check if patient has had a bowel prep, they may be dry, assess for obstruction or signs of full stomach
|-
|Hematologic
|Assess for anticoagulation and possible contraindications to an epidural. DVTs/PEs are major common complications of pancreatic cancer patients
|-
|Renal
|
|-
|Endocrine
|80% have either diabetes or impaired glucose tolerance. Diabetics are at increased risk of MI, CVA, renal infarction
|-
|Other
|Pancreatitis patients tend to be hypotensive and hypovolemic
More than 80% of pancreatic cancers are diagnosed in patients >65y/o with comorbidities.
|}

=== Labs and studies ===

* CBC, BMP, LFTs, coags
* EKG in any patient with risk factors for CAD
*Type and Screen, have 2 units of pRBC on hold
*consider intraoperative labs every 1-2 hours for acid/base, sugars, Hgb (if bleeding concerns),

=== Operating room setup ===

* A-line setup
* Have insulin available in the room

=== Patient preparation and premedication ===

* Many are ERAS pathway
*Strongly consider acetaminophen, gabapentin, celecoxib, particularly if epidural is not used

=== Regional and neuraxial techniques ===

* Preoperative epidural placement is common
*TAP block can be administered if there is no epidural placement

== Intraoperative management ==

=== Monitoring and access ===

* A-line, 2 large-bore PIVs
* CVP is not as common anymore
* NG tube should be placed and taped for postop

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

* Regular glucose checks and insulin infusion titration should occur throughout the procedure
*Consider epidural maintainance for intraop pain if BP tolerates (e.g. bupivacaine 0.125% 5-10 mL/hr)
*Consider ketamine bolus (0.5 mg/kg) and infusion (0.2-0.3 mg/kg/hr), especially if epidural is not used

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* ICU

=== Pain management ===

* Epidural can be used for postoperative pain management

=== Potential complications ===

* Pulmonary complications occur following pancreatic resections in 25% of patients. Pulmonary recruitment is important with upper abdominal surgery
** Pneumonia
** Failure to wean from ventilator
** Post-extubation respiratory failure represents mortality rate of 1-5%
** Patients with pulmonary disease account for 40% of postoperative complications and 20% of deaths
* Delayed gastric emptying: Usually at 7-10 days the stomach begins to recover function
* Pancreatic fistula
* Bowel leakage from anastomosis
* Hemorrhage
* Abscess
* Pancreatogenic diabetes: Following pancreatic resection, insulin receptors are peripherally upregulated and patients are more sensitive to insulin. Patient is more prone to large swings in glucose.

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Standard Whipple
!Pylorus Preserving Whipple
|-
|Procedure
|Pylorus resected
|The pylorus is not resected
|-
|Position
|
|
|-
|Surgical time
|4-7h
|4-7h
|-
|EBL
|200-800cc
|200-800cc
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Pancreatic surgery]]

Tympanoplasty and/or mastoidectomy

2025-09-10T00:15:35Z

Dominicmangino: mostly formatting

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 1 PIV
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative = Avoid long-acting paralysis for facial nerve monitoring. Succinylcholine induction
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Overview ==

=== Indications: ===
Repair perforated or damaged eardrum, remove mastoid air cells damaged by infection or cholesteatoma

=== Surgical procedure: ===
Incision can be postauricular, endaural or transcanal

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Possibly more prone to laryngospasm of associated with URI
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Patients may have associated otitis or URI
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies===
As indicated by H&P, consider WBC if associated with URI

=== Operating room setup===
NIMS to monitor integrity of facial nerve

===Patient preparation and premedication===
Standard premedication

===Regional and neuraxial techniques===
N/A

==Intraoperative management==

===Monitoring and access ===
Standard monitors, 18g PIV x 1

===Induction and airway management ===
Standard induction, succinycholine for intubation (avoid long acting muscle relaxants), ETT

=== Positioning ===
Supine, HOB often turned 90 or 180 degrees

===Maintenance and surgical considerations ===
Avoid long acting muscle relaxants, volatile anesthetic/TIVA, '''avoid''' N2O, remifentanil to maintain a still patient, dexamethasone and ondansetron as patients are prone to PONV

===Emergence ===
Avoid bucking and straining on ETT, consider deep extubation

==Postoperative management==

===Disposition ===
Routine PACU

===Pain management===

===Potential complications ===
PONV, facial nerve injury

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Panniculectomy

2025-09-10T00:02:22Z

Dominicmangino: Added additional indications, time frames, positioning details, additional preoperative considerations for this population

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 1 (18G)
| monitors = Standard, 5-lead EKG
| considerations_preoperative = Obesity
| considerations_intraoperative = Positioning, fat emboli
| considerations_postoperative = Smooth emergence with minimal bucking to minimize tension on suture line
}}

Panniculectomy is a surgery done to remove stretched out, excess fat and overhanging skin from your abdomen. This can occur after a person undergoes massive weight loss. The skin may hang down and cover your thighs and genitals. Surgery to remove this skin helps improve your health and appearance.

Panniculectomy is different from abdominoplasty. In abdominoplasty, the surgeon will remove extra fat and also tighten your abdominal (belly) muscles. Sometimes, both types of surgery are performed at the same time.

== Overview ==

=== Indications ===
Commonly done after rapid weight loss from (≥ 100lb/45kg) after bariatric surgery. Can also be done in patient's with excess abdominal tissue leading to SSTI (e.g., necrotizing fasciitis)

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Obesity
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|OSA, potential with rapid desaturation during hypoventilation with body habitus
|-
|Gastrointestinal
|H/o bariatric surgery, full stomach
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|DM often poorly controlled
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard monitoring

=== Induction and airway management ===
Standard induction for healthy patients.

Consider rapid sequence intubation in obese patients, those with GI pathology or repeated abdominal surgeries.

Consider video laryngoscopy.

=== Positioning ===

=== Maintenance and surgical considerations ===
Standard maintenance.

Take care when calculating drug doses (lean body mass vs actual body mass)

=== Emergence ===
Smooth emergence. Avoid bucking to minimize tension on suture lines.

Ensure adequate PONV prophylaxis.

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===
IV narcotics

=== Potential complications ===
Fat emboli, DVT, Infection, wound dehiscence

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|Supine
|
|-
|Surgical time
|1-5hr
|
|-
|EBL
|~100cc
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|ileus, infection, dehiscence, DVT
|
|}

== References ==

[[Category:Surgical procedures]]

Dacryocystorhinostomy

2025-09-06T18:26:32Z

Dominicmangino: Filled in some very basic info for case. Source Jaffe Anesthesia and discussion with attending

{{Infobox surgical procedure
| anesthesia_type = GA or MAC
| airway =
| lines_access = 1 PIV
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Overview ==

=== Indications ===
persistent symptomatic obstruction of the nasolacrimal duct

=== Surgical procedure ===
Fistula from canaliculus to nasopharynx is created to bypass obstruction.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's manual of surgical procedures|publisher=Wolters Kluwer Health|year=2019|pages=181-184}}</ref>
!Variant 2
|-
|Unique considerations
|Nasal packing with phenylephrine drains into upper airway. (must suction well)
|
|-
|Position
|Supine, table rotated 90-180
|
|-
|Surgical time
|1-1.5 hours
|
|-
|EBL
|100-200
|
|-
|Postoperative disposition
|home
|
|-
|Pain management
|Pain scores 3-4
|
|-
|Potential complications
|failed drainage, bleeding, infection, CSF leak
|
|}

== References ==

[[Category:Surgical procedures]]

Parathyroidectomy

2025-08-02T23:37:04Z

Dominicmangino: Added details to procedure variant table from JAFFE as well as to positioning

{{Infobox surgical case reference
| anesthesia_type = General
| airway = Neuromonitoring ETT
| lines_access = PIV
| monitors = Standard
5-lead ECG
Temperature
Neuromonitoring
| considerations_preoperative =
| considerations_intraoperative = Relaxation with remifentanil if neuro monitoring
| considerations_postoperative = Hypocalcemia
Recurrent laryngeal nerve palsy
}}A '''parathyroidectomy''' is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies.

==Preoperative management ==

===Patient evaluation===
{| class="wikitable"
|+
! System
!Considerations
|-
|Neurologic
|Hypercalcemia can cause altered mental status, weakness, myalgia, and rarely seizures
|-
|Cardiovascular
|Hypertension and tachycardia are common
|-
|Pulmonary
|Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin)
|-
| Gastrointestinal
|Hypercalcemia can cause constipation, nausea/vomiting
|-
|Hematologic
|
|-
|Renal
|Hypercalcemia can cause polyuria/polydipsia resulting in other electrolyte abnormalities. Also increased risk for nephrolithiasis
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies ===

*EKG
*CBC
*BMP to evaluate calcium, magnesium, phosphate,

===Operating room setup===

===Patient preparation and premedication===
Patients should receive IV fluids and diuresis to control calcium levels.

Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively.

===Regional and neuraxial techniques ===

==Intraoperative management ==

=== Monitoring and access===

*Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve

===Induction and airway management===

* NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring
* Preferably use video laryngoscope so surgery team can confirm lead placement

=== Positioning===

*Supine
* Shoulder roll
*Reverse Trendelenburg or 30 degree HOB elevation
*Head in Gel donut

=== Maintenance and surgical considerations===

*Avoid paralytic for nerve monitoring. Consider remifentanil instead.

=== Emergence===

* Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding
** Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep.

==Postoperative management==

===Disposition ===
Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients.

===Pain management===

===Potential complications ===

* Symptomatic hypocalcemia
*Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback.
*Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy

==Procedure variants ==

{| class="wikitable"
|+
!
! Open
!Minimally invasive (endoscopic)
!Minimally invasive (robotic)
|-
|Unique considerations
|
|
|
|-
|Position
|Supine; shoulder roll; reverse Trendelenberg, headrest with gel donut
|
|
|-
|Surgical time
|1-2h
|
|
|-
|EBL
|25-50mL
|
|
|-
|Postoperative disposition
|PACU to either med surg for Ca monitoring x 24 hours, or PACU to home
|
|
|-
|Pain management
|3-4
|Less than open
|less than open
|-
|Potential complications
|Hypocalcemia: <15%

Hypoparathyroidism: <5%

Hematoma: 1%

Infection: 1%

Recurrent laryngeal paralysis: <1%
|
|
|}

==References==

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Endocrine surgery]]