Position: Supine, Reverse Trendelenburg, arms tucked
Time: 1-2 hours (average)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Approach – General/ETT, possible RSI. These procedures can also be done robotically.

Obesity – Most of these patients will have obesity related health problems (eg. Obstructive Sleep Apnea, Diabetes, neck and back pain).

Difficult intubation – There is an estimated 1-15% of this population that will be a difficult intubation. In one study, 43% of these patients had restricted neck movement. Do a thorough assessment, give plenty of time to preoxygenate, and have a video laryngoscope close/ready.

OG tube – Insert OG tube shortly after induction to clear stomach contents prior to the procedure. Decompression and removal of stomach contents very important prior to incision, so make sure OG tube is in the correctly placed. The laparoscopic camera will visualize the stomach and this will be a great time to make sure it has been decompressed. Once this is visualized, it is VERY IMPORTANT to make sure the OG tube is removed prior to the surgeon stapling the stomach. Let surgeon know when the OG tube has been removed (getting the OG tube caught in the staples would be a huge problem).

Bougie – After the OG tube is out and when the surgeon asks, place a bougie down the esophagus (make sure it is well lubricated, and do not force it if you meet resistance). Surgeon will let you know what size (commonly 34F) and how far to place it.

PONV – PONV is a common post-operative problem after these surgeries. Consider giving a full range of antiemetics for PONV prophylaxis.

Awake extubations – Its generally safest to extubate these patients awake.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Laparoscopic cases (general considerations): The patient’s peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen. General anesthesia, ETT tube, and paralytics are necessary. Some of the procedures are rather short, so make sure the timing is right to reverse the paralytic. The pressure in peritoneum affects the organs of that space. Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Peak inspiratory pressures rise. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS). Reduced blood to the kidney means reduced urine output. Peak inspiratory and plateau pressures will also increase. The gas used to insufflate the peritoneum is CO2 – so, as you might guess, hypercarbia can develop – and with it, acidosis. You’ll see this sometimes reflected in the end-tidal CO2. This is all adding to the stress response we try to avoid in anesthesia.

Gastric sleeve surgery is a bariatric surgery performed on obese patients that involves stapling and removing up to 80% of the stomach. The reduced volume of the stomach leads to the patient to eating less, which aids in losing weight.