WikiAnesthesia - User contributions [en]

Cystectomy

2025-10-03T16:19:40Z

Sglier1: added considerations for ileal conduit & neobladder creation

{{Infobox surgical case reference
| anesthesia_type = General / Neuraxial
| airway = ETT
| lines_access = Partial: PIV x 1 (20) 
Radical: PIV x 2 (18 or 16)
| monitors = Partial: Standard 
Radical: Std + art line
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative = hemorrhage, wound infection, DVT, UTI, ureterointestinal leakage, ileus
}}

A cystectomy is the removal of all or part of the urinary bladder. Most commonly, this procedure is performed to address cancer. May be combined with prostatectomy, ileal conduit, or neobladder reconstruction.

== Preoperative management ==

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

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

* If spinal used, ensure T4 sensory level
** Consider using epi in spinal to prolong block
* Can consider placing epidural if significant post-op pain anticipated

== Intraoperative management ==

=== Monitoring and access ===

* 2 PIVs for open, radical, or robotic cystectomy (18g+)

=== Induction and airway management ===

* GETA

=== Positioning ===

* Supine
* Sometimes females placed in lithotomy

=== Maintenance and surgical considerations ===

* If robotic, patient will be in steep Trendelenburg for a large portion of the case
*If radical cystectomy, have T&S and consider T&C 2 units
* Some centers use indocyanine 25mg to visualize blood flow to the ureters
*If construction of ileal conduit or neobladder, surgeons generally like to keep the patient dry to prevent diuresis and high UOP during the case; liberalize fluid goals after completion of anastamoses

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* PACU

=== Pain management ===

=== Potential complications ===

* Bleeding

== Procedure variants ==

{| class="wikitable"
|+
!
!Radical cystectomy
!Partial Cystectomy
!Open cystectomy
!Minimally invasive cystectomy
!Robotic cystectomy
|-
|Unique considerations
|Involves removal of entire bladder, nearby lymph nodes, part of the urethra, and nearby organs that may contain cancer cells
|Possible when the cancerous lesion is located in the dome of the bladder. Does not require urinary diversion
|Simple, open cystectomy involves removal of the entire bladder without removal of any adjacent structures or organs. Urinary diversion is then created.
|
|
|-
|Position
|Supine, sometimes lithotomy for females
|Supine
|Supine, one or both arms out
|
|Steep Trendelenburg
|-
|Surgical time
|4-6 hours
|~ 2 hours (urinary diversion not required)
|
|
|~ 4-6 hrs
|-
|EBL
|300-1500
|Minimal
|1000mL
|
|100-200mL
|-
|Postoperative disposition
|
|
|
|
|PACU
|-
|Pain management
|
|
|
|
|2
|-
|Potential complications
|
|
|
|
|
|}

== References ==

[[Category:Surgical procedures]]
[[Category:Urology]]

Glaucoma surgery: MIGS, trabeculectomy, and others

2025-08-07T18:39:04Z

Sglier1: updated page w/ additional considerations

{{Infobox surgical procedure
| anesthesia_type = MAC
| airway = Noninvasive O2
| lines_access = PIV
| monitors = Standard, 5 lead ECG
| considerations_preoperative =
| considerations_intraoperative = Oculocardiac reflex
| considerations_postoperative =
}}

Open-angle glaucoma (OAG) is the most common form of glaucoma and is characterized by a gradual increase in intraocular pressure (IOP) due to the slow blockage of the drainage canals in the eye. Management includes medications, laser therapies, and surgical procedures including minimally invasive glaucoma surgery (MIGS). MIGS aims to lower IOP with less risk and faster recovery than traditional surgeries.

== Overview ==

=== Indications ===
Failure of medical and laser therapy to adequately control IOP or continued progression of optic nerve or visual field damage despite maximal tolerated non-surgical treatment.

=== Surgical procedure ===

# Laser therapies
#* Laser Trabeculoplasty: This procedure uses a laser to improve the drainage of fluid through the trabecular meshwork
#* Selective Laser Trabeculoplasty (SLT): A more recent and less invasive option that targets specific cells in the trabecular meshwork and can be repeated if necessary
# Surgical procedures
#* Trabeculectomy: creates a new drainage pathway to reduce IOP by removing a part of the trabecular meshwork and sclera
#* Tube Shunt Surgery: Involves placing a small tube (shunt) in the eye to assist with the drainage of aqueous humor
# MIGS
#* iStent: A tiny device that creates a new drain for fluid
#* Hydrus Microstent: A small stent implanted in the drainage canal to help fluid drain better
#* Kahook Dual Blade: A technique that removes tissue in the trabecular meshwork to facilitate drainage

== 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 ===
Regional blocks are briefly painful and stimulating. Consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg) prior to block. Prepare to treat apnea or drop in BP.
#Peribulbar block: injecting a local anesthetic into the space surrounding the eye (the peribulbar space). Provides a dense block of the sensory nerves supplying the eye and can also induce temporary paralysis of the ocular muscles. Risks include potential injury to the optic nerve, hemorrhage, or globe perforation
# Retrobulbar block: local anesthetic injected behind the eyeball (retrobulbar space) to block the optic nerve and other sensory nerves. Provides profound anesthesia for the eye. Can also produce akinesia (paralysis of eye movement). Higher risk block including potential injury to the optic nerve, hemorrhage, globe perforation, or systemic toxicity
# Subtenon block: anesthetic injected into the subtenon space, which is located just outside the sclera (the white part of the eye but under the Tenon's capsule). Allows anesthetic to diffuse around the eye. Lower risk of complications compared to the above blocks. Will have preservation of eye movement which may be suboptimal for surgical conditions.

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* 5 Lead EKG
* 1 Peripheral IV

=== Induction and airway management ===

* Most commonly use nasal cannula for O2 supplementation, but LMA for select patient populations
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
* Consider use of precedex as an adjunct throughout case given its sedative effects and ability to lower the IOP<ref>{{Cite journal|last=Senthil|first=Sirisha|last2=Burugupally|first2=Keerthi|last3=Rout|first3=Umashankar|last4=Rao|first4=Harsha L.|last5=Krishnamurthy|first5=Rashmi|last6=Badakere|first6=Swathi|last7=Choudhari|first7=Nikhil|last8=Garudadri|first8=Chandrasekhar|date=2020-10|title=Effect of Intravenous Dexmedetomidine on Intraocular Pressure in Patients Undergoing Glaucoma Surgery Under Local Anesthesia: A Pilot Study|url=https://pubmed.ncbi.nlm.nih.gov/32740512|journal=Journal of Glaucoma|volume=29|issue=10|pages=846–850|doi=10.1097/IJG.0000000000001621|issn=1536-481X|pmid=32740512}}</ref><ref>{{Cite journal|last=Pereira|first=Eduardo Maia Martins|last2=Viana|first2=Patrícia|last3=da Silva|first3=Rodrigo Araujo Monteiro|last4=Silott|first4=Pedro Furlan|last5=Amaral|first5=Sara|date=2025-02|title=Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetics in Peribulbar Block: A Meta-analysis With Trial-Sequential Analysis|url=https://pubmed.ncbi.nlm.nih.gov/39033834|journal=American Journal of Ophthalmology|volume=270|pages=140–153|doi=10.1016/j.ajo.2024.07.011|issn=1879-1891|pmid=39033834}}</ref>

=== Positioning ===

* supine

=== Maintenance and surgical considerations ===

* Short cases ranging between 30 - 90 min depending on complexity and technique
* Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure
** Stop surgical manipulation, give [[atropine]]/[[glycopyrrolate]]

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* Short post-op monitoring
* Usually home same day

=== Pain management ===

* Tylenol
* +/- Ketorolac

=== Potential complications ===

* hemorrhage
* infection
* cataract formation
* corneal edema
* ocular hypotony (IOP iatrogenically too low)

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Glaucoma surgery: MIGS, trabeculectomy, and others

2025-08-07T18:11:04Z

Sglier1: started a page for trabeculectomies and other glaucoma specific procedures

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Open-angle glaucoma (OAG) is the most common form of glaucoma and is characterized by a gradual increase in intraocular pressure (IOP) due to the slow blockage of the drainage canals in the eye. Management includes medications, laser therapies, and surgical procedures including minimally invasive glaucoma surgery (MIGS). MIGS aims to lower IOP with less risk and faster recovery than traditional surgeries.

== Overview ==

=== Indications ===
Failure of medical and laser therapy to adequately control IOP or continued progression of optic nerve or visual field damage despite maximal tolerated non-surgical treatment.

=== Surgical procedure ===

# Laser therapies
#* Laser Trabeculoplasty: This procedure uses a laser to improve the drainage of fluid through the trabecular meshwork
#* Selective Laser Trabeculoplasty (SLT): A more recent and less invasive option that targets specific cells in the trabecular meshwork and can be repeated if necessary
# Surgical procedures
#* Trabeculectomy: creates a new drainage pathway to reduce IOP by removing a part of the trabecular meshwork and sclera
#* Tube Shunt Surgery: Involves placing a small tube (shunt) in the eye to assist with the drainage of aqueous humor
# MIGS
#* iStent: A tiny device that creates a new drain for fluid
#* Hydrus Microstent: A small stent implanted in the drainage canal to help fluid drain better
#* Kahook Dual Blade: A technique that removes tissue in the trabecular meshwork to facilitate drainage

== 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 ===

# Peribulbar block: injecting a local anesthetic into the space surrounding the eye (the peribulbar space). Provides a dense block of the sensory nerves supplying the eye and can also induce temporary paralysis of the ocular muscles. Risks include potential injury to the optic nerve, hemorrhage, or globe perforation
# Retrobulbar block: local anesthetic injected behind the eyeball (retrobulbar space) to block the optic nerve and other sensory nerves. Provides profound anesthesia for the eye. Can also produce akinesia (paralysis of eye movement). Higher risk block including potential injury to the optic nerve, hemorrhage, globe perforation, or systemic toxicity
# Subtenon block: anesthetic injected into the subtenon space, which is located just outside the sclera (the white part of the eye but under the Tenon's capsule). Allows anesthetic to diffuse around the eye. Lower risk of complications compared to the above blocks. Will have preservation of eye movement which may be suboptimal for surgical conditions.

== 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
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Breast reconstruction

2025-07-22T22:27:37Z

Sglier1: typo fixes

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.<ref>{{Cite journal|last=Bellini|first=Elisa|last2=Pesce|first2=Marianna|last3=Santi|first3=PierLuigi|last4=Raposio|first4=Edoardo|date=2017|title=Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique|url=https://pubmed.ncbi.nlm.nih.gov/29376067|journal=BioMed Research International|volume=2017|pages=1791546|doi=10.1155/2017/1791546|issn=2314-6141|pmc=5742435|pmid=29376067}}</ref>

Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.<ref>{{Cite journal|last=Gerber|first=Bernd|last2=Marx|first2=Mario|last3=Untch|first3=Michael|last4=Faridi|first4=Andree|date=2015-08-31|title=Breast Reconstruction Following Cancer Treatment|url=https://pubmed.ncbi.nlm.nih.gov/26377531|journal=Deutsches Arzteblatt International|volume=112|issue=35-36|pages=593–600|doi=10.3238/arztebl.2015.0593|issn=1866-0452|pmc=4577667|pmid=26377531}}</ref>

==Overview==
===Indications===
===Surgical procedure===

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|respiratory compromise can be present if pt had XRT to thorax
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===
Regional techniques include thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block.

* Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is effective for mastectomy with or without recon, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.<ref>{{Cite journal|last=Calì Cassi|first=L.|last2=Biffoli|first2=F.|last3=Francesconi|first3=D.|last4=Petrella|first4=G.|last5=Buonomo|first5=O.|date=2017-03|title=Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block|url=https://pubmed.ncbi.nlm.nih.gov/28387892|journal=European Review for Medical and Pharmacological Sciences|volume=21|issue=6|pages=1341–1345|issn=2284-0729|pmid=28387892}}</ref><ref>{{Cite journal|last=FitzGerald|first=Simon|last2=Odor|first2=Peter M.|last3=Barron|first3=Ann|last4=Pawa|first4=Amit|date=2019-03|title=Breast surgery and regional anaesthesia|url=https://pubmed.ncbi.nlm.nih.gov/31272657|journal=Best Practice & Research. Clinical Anaesthesiology|volume=33|issue=1|pages=95–110|doi=10.1016/j.bpa.2019.03.003|issn=1878-1608|pmid=31272657}}</ref>
* Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are favored for their safety profile and can be combined with PVB for extensive procedures.<ref>{{Cite journal|last=Abi-Rafeh|first=Jad|last2=Safran|first2=Tyler|last3=Abi-Jaoude|first3=Joanne|last4=Kazan|first4=Roy|last5=Alabdulkarim|first5=Abdulaziz|last6=Davison|first6=Peter G.|date=2022-07-01|title=Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy|url=https://pubmed.ncbi.nlm.nih.gov/35499513|journal=Plastic and Reconstructive Surgery|volume=150|issue=1|pages=1e–12e|doi=10.1097/PRS.0000000000009253|issn=1529-4242|pmid=35499513}}</ref><ref>{{Cite journal|last=Matsumoto|first=Marcio|last2=Flores|first2=Eva M.|last3=Kimachi|first3=Pedro P.|last4=Gouveia|first4=Flavia V.|last5=Kuroki|first5=Mayra A.|last6=Barros|first6=Alfredo C. S. D.|last7=Sampaio|first7=Marcelo M. C.|last8=Andrade|first8=Felipe E. M.|last9=Valverde|first9=João|last10=Abrantes|first10=Eduardo F.|last11=Simões|first11=Claudia M.|date=2018-05-18|title=Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/29777144|journal=Scientific Reports|volume=8|issue=1|pages=7815|doi=10.1038/s41598-018-26273-z|issn=2045-2322|pmc=5959858|pmid=29777144}}</ref>

Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===
For both implant-based and autologous recons, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk).

For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type.

After placement of implant or flap, surgeon will typically ask for HOB up 90 degrees to assess symmetry.

===Maintenance and surgical considerations===
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs.

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.<ref>{{Cite journal|last=Bennett|first=Katelyn G.|last2=Qi|first2=Ji|last3=Kim|first3=Hyungjin M.|last4=Hamill|first4=Jennifer B.|last5=Pusic|first5=Andrea L.|last6=Wilkins|first6=Edwin G.|date=2018-10-01|title=Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction|url=https://doi.org/10.1001/jamasurg.2018.1687|journal=JAMA Surgery|volume=153|issue=10|pages=901–908|doi=10.1001/jamasurg.2018.1687|issn=2168-6254}}</ref>

* Seroma
* Hematoma
* Implant reconstruction:
** Capsular contracture
** Implant malposition / rupture / leakage
* Autologous reconstruction:
** Flap thrombosis can lead to necrosis
*** monitoring for flap perfusion is critical in autologous reconstruction
** Fat necrosis
** Hernia

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Breast reconstruction

2025-07-22T22:23:56Z

Sglier1:

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.<ref>{{Cite journal|last=Bellini|first=Elisa|last2=Pesce|first2=Marianna|last3=Santi|first3=PierLuigi|last4=Raposio|first4=Edoardo|date=2017|title=Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique|url=https://pubmed.ncbi.nlm.nih.gov/29376067|journal=BioMed Research International|volume=2017|pages=1791546|doi=10.1155/2017/1791546|issn=2314-6141|pmc=5742435|pmid=29376067}}</ref>

Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.<ref>{{Cite journal|last=Gerber|first=Bernd|last2=Marx|first2=Mario|last3=Untch|first3=Michael|last4=Faridi|first4=Andree|date=2015-08-31|title=Breast Reconstruction Following Cancer Treatment|url=https://pubmed.ncbi.nlm.nih.gov/26377531|journal=Deutsches Arzteblatt International|volume=112|issue=35-36|pages=593–600|doi=10.3238/arztebl.2015.0593|issn=1866-0452|pmc=4577667|pmid=26377531}}</ref>

==Overview==
===Indications===
===Surgical procedure===

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|respiratory compromise can be present if pt had XRT to thorax
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===
The most established regional techniques are thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block.

* Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is particularly effective for mastectomy with or without reconstruction, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.<ref>{{Cite journal|last=Calì Cassi|first=L.|last2=Biffoli|first2=F.|last3=Francesconi|first3=D.|last4=Petrella|first4=G.|last5=Buonomo|first5=O.|date=2017-03|title=Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block|url=https://pubmed.ncbi.nlm.nih.gov/28387892|journal=European Review for Medical and Pharmacological Sciences|volume=21|issue=6|pages=1341–1345|issn=2284-0729|pmid=28387892}}</ref><ref>{{Cite journal|last=FitzGerald|first=Simon|last2=Odor|first2=Peter M.|last3=Barron|first3=Ann|last4=Pawa|first4=Amit|date=2019-03|title=Breast surgery and regional anaesthesia|url=https://pubmed.ncbi.nlm.nih.gov/31272657|journal=Best Practice & Research. Clinical Anaesthesiology|volume=33|issue=1|pages=95–110|doi=10.1016/j.bpa.2019.03.003|issn=1878-1608|pmid=31272657}}</ref>
* Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are increasingly favored for their safety profile and versatility, and can be combined with PVB for extensive procedures.<ref>{{Cite journal|last=Abi-Rafeh|first=Jad|last2=Safran|first2=Tyler|last3=Abi-Jaoude|first3=Joanne|last4=Kazan|first4=Roy|last5=Alabdulkarim|first5=Abdulaziz|last6=Davison|first6=Peter G.|date=2022-07-01|title=Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy|url=https://pubmed.ncbi.nlm.nih.gov/35499513|journal=Plastic and Reconstructive Surgery|volume=150|issue=1|pages=1e–12e|doi=10.1097/PRS.0000000000009253|issn=1529-4242|pmid=35499513}}</ref><ref>{{Cite journal|last=Matsumoto|first=Marcio|last2=Flores|first2=Eva M.|last3=Kimachi|first3=Pedro P.|last4=Gouveia|first4=Flavia V.|last5=Kuroki|first5=Mayra A.|last6=Barros|first6=Alfredo C. S. D.|last7=Sampaio|first7=Marcelo M. C.|last8=Andrade|first8=Felipe E. M.|last9=Valverde|first9=João|last10=Abrantes|first10=Eduardo F.|last11=Simões|first11=Claudia M.|date=2018-05-18|title=Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/29777144|journal=Scientific Reports|volume=8|issue=1|pages=7815|doi=10.1038/s41598-018-26273-z|issn=2045-2322|pmc=5959858|pmid=29777144}}</ref>
* Erector spinae plane block is an emerging technique with promising results, but less extensive data compared to PVB and PECS blocks.<ref>{{Cite journal|last=Wong|first=Heung-Yan|last2=Pilling|first2=Rob|last3=Young|first3=Bruce W. M.|last4=Owolabi|first4=Adetokunbo A.|last5=Onwochei|first5=Desire N.|last6=Desai|first6=Neel|date=2021-09|title=Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/33873002|journal=Journal of Clinical Anesthesia|volume=72|pages=110274|doi=10.1016/j.jclinane.2021.110274|issn=1873-4529|pmid=33873002}}</ref>
* Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===
For both implant-based and autologous recons, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk).

For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type.

After placement of implant or flap, surgeon will typically ask for HOB up 90 degrees to assess symmetry.

===Maintenance and surgical considerations===
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs.

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.<ref>{{Cite journal|last=Bennett|first=Katelyn G.|last2=Qi|first2=Ji|last3=Kim|first3=Hyungjin M.|last4=Hamill|first4=Jennifer B.|last5=Pusic|first5=Andrea L.|last6=Wilkins|first6=Edwin G.|date=2018-10-01|title=Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction|url=https://doi.org/10.1001/jamasurg.2018.1687|journal=JAMA Surgery|volume=153|issue=10|pages=901–908|doi=10.1001/jamasurg.2018.1687|issn=2168-6254}}</ref>

* Seroma
* Hematoma
* Implant reconstruction:
** Capsular contracture
** Implant malposition / rupture / leakage
* Autologous reconstruction:
** Flap thrombosis can lead to necrosis
*** monitoring for flap perfusion is critical in autologous reconstruction
** Fat necrosis
** Hernia

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Breast reconstruction

2025-07-22T22:19:42Z

Sglier1: added more info in regional section, complications, positioning

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.<ref>{{Cite journal|last=Bellini|first=Elisa|last2=Pesce|first2=Marianna|last3=Santi|first3=PierLuigi|last4=Raposio|first4=Edoardo|date=2017|title=Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique|url=https://pubmed.ncbi.nlm.nih.gov/29376067|journal=BioMed Research International|volume=2017|pages=1791546|doi=10.1155/2017/1791546|issn=2314-6141|pmc=5742435|pmid=29376067}}</ref>

Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.<ref>{{Cite journal|last=Gerber|first=Bernd|last2=Marx|first2=Mario|last3=Untch|first3=Michael|last4=Faridi|first4=Andree|date=2015-08-31|title=Breast Reconstruction Following Cancer Treatment|url=https://pubmed.ncbi.nlm.nih.gov/26377531|journal=Deutsches Arzteblatt International|volume=112|issue=35-36|pages=593–600|doi=10.3238/arztebl.2015.0593|issn=1866-0452|pmc=4577667|pmid=26377531}}</ref>

==Overview==
===Indications===
===Surgical procedure===

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|respiratory compromise can be present if pt had XRT to thorax
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===
The most established regional techniques are thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block.

* Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is particularly effective for mastectomy with or without reconstruction, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.<ref>{{Cite journal|last=Calì Cassi|first=L.|last2=Biffoli|first2=F.|last3=Francesconi|first3=D.|last4=Petrella|first4=G.|last5=Buonomo|first5=O.|date=2017-03|title=Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block|url=https://pubmed.ncbi.nlm.nih.gov/28387892|journal=European Review for Medical and Pharmacological Sciences|volume=21|issue=6|pages=1341–1345|issn=2284-0729|pmid=28387892}}</ref><ref>{{Cite journal|last=FitzGerald|first=Simon|last2=Odor|first2=Peter M.|last3=Barron|first3=Ann|last4=Pawa|first4=Amit|date=2019-03|title=Breast surgery and regional anaesthesia|url=https://pubmed.ncbi.nlm.nih.gov/31272657|journal=Best Practice & Research. Clinical Anaesthesiology|volume=33|issue=1|pages=95–110|doi=10.1016/j.bpa.2019.03.003|issn=1878-1608|pmid=31272657}}</ref>
* Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are increasingly favored for their safety profile and versatility, and can be combined with PVB for extensive procedures.<ref>{{Cite journal|last=Abi-Rafeh|first=Jad|last2=Safran|first2=Tyler|last3=Abi-Jaoude|first3=Joanne|last4=Kazan|first4=Roy|last5=Alabdulkarim|first5=Abdulaziz|last6=Davison|first6=Peter G.|date=2022-07-01|title=Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy|url=https://pubmed.ncbi.nlm.nih.gov/35499513|journal=Plastic and Reconstructive Surgery|volume=150|issue=1|pages=1e–12e|doi=10.1097/PRS.0000000000009253|issn=1529-4242|pmid=35499513}}</ref><ref>{{Cite journal|last=Matsumoto|first=Marcio|last2=Flores|first2=Eva M.|last3=Kimachi|first3=Pedro P.|last4=Gouveia|first4=Flavia V.|last5=Kuroki|first5=Mayra A.|last6=Barros|first6=Alfredo C. S. D.|last7=Sampaio|first7=Marcelo M. C.|last8=Andrade|first8=Felipe E. M.|last9=Valverde|first9=João|last10=Abrantes|first10=Eduardo F.|last11=Simões|first11=Claudia M.|date=2018-05-18|title=Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/29777144|journal=Scientific Reports|volume=8|issue=1|pages=7815|doi=10.1038/s41598-018-26273-z|issn=2045-2322|pmc=5959858|pmid=29777144}}</ref>
* Erector spinae plane block is an emerging technique with promising results, but less extensive data compared to PVB and PECS blocks.<ref>{{Cite journal|last=Wong|first=Heung-Yan|last2=Pilling|first2=Rob|last3=Young|first3=Bruce W. M.|last4=Owolabi|first4=Adetokunbo A.|last5=Onwochei|first5=Desire N.|last6=Desai|first6=Neel|date=2021-09|title=Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/33873002|journal=Journal of Clinical Anesthesia|volume=72|pages=110274|doi=10.1016/j.jclinane.2021.110274|issn=1873-4529|pmid=33873002}}</ref>
* Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===
For both implant-based and autologous reconstructions, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk).

For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type.

===Maintenance and surgical considerations===
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs.

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.<ref>{{Cite journal|last=Bennett|first=Katelyn G.|last2=Qi|first2=Ji|last3=Kim|first3=Hyungjin M.|last4=Hamill|first4=Jennifer B.|last5=Pusic|first5=Andrea L.|last6=Wilkins|first6=Edwin G.|date=2018-10-01|title=Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction|url=https://doi.org/10.1001/jamasurg.2018.1687|journal=JAMA Surgery|volume=153|issue=10|pages=901–908|doi=10.1001/jamasurg.2018.1687|issn=2168-6254}}</ref>

* Seroma
* Hematoma
* Implant reconstruction:
** Capsular contracture
** Implant malposition / rupture / leakage
* Autologous reconstruction:
** Flap thrombosis can lead to necrosis
*** monitoring for flap perfusion is critical in autologous reconstruction
** Fat necrosis
** Hernia

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Breast reconstruction

2025-07-22T20:03:08Z

Sglier1: started a page for breast recon, not completed

Cranioplasty

2025-07-15T23:10:16Z

Sglier1: created a new page and uploaded basic info

The purpose of a cranioplasty is to surgically repair cranial defects, most commonly following decompressive craniectomy, trauma, tumor resection, or infection.

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

== Overview ==

=== Indications ===
Repair cranial defects, restore the protective barrier of the skull, improve cerebral protection, and re-establish normal cranial contour for cosmetic reasons.<ref>{{Cite journal|last=Alkhaibary|first=Ali|last2=Alharbi|first2=Ahoud|last3=Alnefaie|first3=Nada|last4=Oqalaa Almubarak|first4=Abdulaziz|last5=Aloraidi|first5=Ahmed|last6=Khairy|first6=Sami|date=2020-07|title=Cranioplasty: A Comprehensive Review of the History, Materials, Surgical Aspects, and Complications|url=https://pubmed.ncbi.nlm.nih.gov/32387405|journal=World Neurosurgery|volume=139|pages=445–452|doi=10.1016/j.wneu.2020.04.211|issn=1878-8769|pmid=32387405}}</ref> Additionally, cranioplasty can normalize cerebrospinal fluid dynamics, potentially improving neurological function and facilitating neurorehabilitation.<ref>{{Cite journal|last=Pasick|first=Christina Marie|last2=Margetis|first2=Konstantinos|last3=Santiago|first3=Gabriel F.|last4=Gordon|first4=Chad|last5=Taub|first5=Peter J.|date=2019-10|title=Adult Cranioplasty|url=https://pubmed.ncbi.nlm.nih.gov/31478955|journal=The Journal of Craniofacial Surgery|volume=30|issue=7|pages=2138–2143|doi=10.1097/SCS.0000000000005659|issn=1536-3732|pmid=31478955}}</ref> Restoration of the skull also helps prevent complications such as the syndrome of the trephined (sinking skin flap syndrome) and may improve cognitive and motor outcomes by optimizing cerebral hemodynamics and metabolism.<ref>{{Cite journal|last=Piazza|first=Matthew|last2=Grady|first2=M. Sean|date=2017-04|title=Cranioplasty|url=https://pubmed.ncbi.nlm.nih.gov/28325460|journal=Neurosurgery Clinics of North America|volume=28|issue=2|pages=257–265|doi=10.1016/j.nec.2016.11.008|issn=1558-1349|pmid=28325460}}</ref>

=== Surgical procedure ===

== 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
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]