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    Principles of Safe Laparos

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    olyviutza16
    The document discusses laparoscopic entry techniques including primary port closed entry using a Veress needle, secondary port entry under direct vision, alternatives to closed umbilical entry, and exit techniques. It also references guidelines on preventing entry-related injuries from the Royal College of Obstetricians and Gynaecologists.

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    Principles of Safe Laparos

    Uploaded by

    olyviutza16
    237 views28 pages
    The document discusses laparoscopic entry techniques including primary port closed entry using a Veress needle, secondary port entry under direct vision, alternatives to closed umbilical entry, and exit techniques. It also references guidelines on preventing entry-related injuries from the Royal College of Obstetricians and Gynaecologists.

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    Principles of Safe Laparoscopy

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    The document discusses laparoscopic entry techniques including primary port closed entry using a Veress needle, secondary port entry under direct vision, alternatives to closed umbilical entry, and exit techniques. It also references guidelines on preventing entry-related injuries from the Royal College of Obstetricians and Gynaecologists.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    237 views28 pages

    Principles of Safe Laparos

    Uploaded by

    olyviutza16
    The document discusses laparoscopic entry techniques including primary port closed entry using a Veress needle, secondary port entry under direct vision, alternatives to closed umbilical entry, and exit techniques. It also references guidelines on preventing entry-related injuries from the Royal College of Obstetricians and Gynaecologists.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 28

    Laparoscopy and entry

    RCOG Basic Practical Skills

    Laparoscopic entry techniques


    What to expect:
    1. Position of patient
    2. Primary port closed entry
    3. Secondary port entry
    4. Primary port alternatives
    5. Exit techniques
    6. Reference to RCOG Green Top
    Guideline 49 - PREVENTING ENTRYRELATED GYNAECOLOGICAL
    LAPAROSCOPIC INJURIES
    Royal College of Obstetricians and Gynaecologists

    1. Position

    Prone
    Stirrups/Lloyd Davis
    Non slip mattress
    Trendelenberg after ports

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May 2008


    The operating table should be
    horizontal (not in the Trendelenberg
    tilt) at the start of the procedure
    The abdomen should be palpated to
    check for any masses before insertion
    of the Veress needle

    Royal College of Obstetricians and Gynaecologists

    2. Primary port
    closed
    entry
    Why intra umbilical entry?

    Fixed peritoneum
    Thin
    Least vascular
    Cosmetic

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May 2008


    The primary incision for laparoscopy
    should be vertical from the base of the
    umbilicus (not in the skin below the
    umbilicus)
    Care should be taken not to incise so
    deeply as to enter the peritoneal cavity.

    Royal College of Obstetricians and Gynaecologists

    2. Primary port
    closed
    entry
    Insertion of Veress needle
    Pencil grip
    Vertical, then towards pelvis
    Double click

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    The Veress needle should be sharp, with
    a good and tested spring action. A
    disposable needle is recommended
    The lower abdominal wall should be
    stabilised in such a way that the Veress
    needle can be inserted at right angles to
    the skin
    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    Two audible clicks are usually heard as the
    layers of the umbilicus are penetrated.
    Excessive lateral movement of the needle
    should be avoided. This may convert a small
    needle point injury in the wall of the bowel or
    vessel into a complex tear

    Royal College of Obstetricians and Gynaecologists

    2. Primary port closed entry


    Saline test
    Withdraw
    Instil
    Withdraw

    If no fluid, frank blood (or faeces) then


    proceed with insufflation
    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May 2008

    The saline test not 100% accurate


    The most valuable test of correct placement
    of the Veress needle is to observe that the
    initial insufflation pressure is relatively low
    (less than 8mmHg) and is flowing freely
    After 2 failed attempts to insert the Veress
    needle, either the open Hasson technique
    or Palmers point entry should be used.
    Royal College of Obstetricians and Gynaecologists

    2. Primary port closed entry


    Insufflation
    Set pressure cut of to at least 20-25mmHg
    Start at low flow (1L/min)
    Check gas entering at low pressure
    (<8mmHg)
    After 0.5L flow rate can be increased
    Insufflate to pressure cut of (20-25mmHg)

    Royal College of Obstetricians and Gynaecologists

    2. Primary port closed entry


    The greater the gas bubble &
    abdominal wall tension the less the
    risk of bowel injury
    Abdominal pressure= 8mmHg

    Abdominal pressure=25mmHg

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008

    An intra-abdominal pressure of 2025


    mmHg should be achieved before
    inserting the primary trocar
    The distension pressure should be
    reduced to 1215 mmHg once the
    insertion of the trocars is complete

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    The primary trocar should be inserted at 90
    degrees to the skin, through the incision at
    the base of the umbilicus
    Once the laparoscope has been introduced it
    should be rotated through 360 degrees to
    check for any adherent bowel

    Royal College of Obstetricians and Gynaecologists

    2. Primary port
    closed
    entry
    Commonest problem - failed entry

    Insertion of subumbilical Veress needle

    Royal College of Obstetricians and Gynaecologists

    2. Primary port closed entry


    Closed entry can still cause bowel
    injury, especially if adhesions are
    present

    Royal College of Obstetricians and Gynaecologists

    2. Primary port
    closed entry

    Other injuries
    Vascular injury
    Retroperitoneal
    haemorrhage
    Bladder injury
    Injury to over inflated
    stomach

    Royal College of Obstetricians and Gynaecologists

    3. Secondary ports
    Secondary ports are inserted under
    direct vision - an inadvertent injury from
    a secondary port could be considered
    negligent
    Principles
    Avoid inferior epigastric vessels
    Avoid bowel/vascular injury
    Minimise hernia risk

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    Secondary ports inserted under direct
    vision at right angles to the skin at 2025
    mmHg pneumoperitoneum
    Inferior epigastric vessels should be
    visualised laparoscopically prior to
    secondary port placement
    Once the trocar has pierced the
    peritoneum it should be angled towards
    the anterior pelvis
    Royal College of Obstetricians and Gynaecologists

    3. Secondary ports Anatomy

    Mid-line
    Rectus muscles
    Obliterated umbilical artery

    Round ligament

    Royal College of Obstetricians and Gynaecologists

    3. Secondary ports Anatomy


    Inf epigastric artery

    Royal College of Obstetricians and Gynaecologists

    4. Primary port
    Alternatives

    Alternatives to closed umbilical entry


    considered:
    If there is risk of umbilical adhesions previous (midline) laparotomy
    In very slim or morbidly obese women
    Failed saline test or Veress insertion x2
    Unsatisfactory closed Veress insufflation

    Alternatives include:
    Open entry variations of Hassan technique
    Palmers point closed entry
    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    When Hasson open laparoscopic entry is
    employed, confirm that the peritoneum has
    been opened by visualising bowel or
    omentum
    Palmers point is the preferred alternative
    trocar insertion site, except in cases of
    previous surgery in this area or
    splenomegaly.
    Royal College of Obstetricians and Gynaecologists

    5. Exit techniques
    Under direct view to identify:
    Bleeding
    Injury to omentum
    Injury to bowel
    - (partial/complete)

    Royal College of Obstetricians and Gynaecologists

    Green-top Guideline. No. 49 May


    2008
    On removal of a laparoscope. Check by
    direct visualisation that there has not
    been a through-and-through injury of
    bowel adherent under the umbilicus
    Secondary ports must be removed under
    direct vision to ensure that any
    haemorrhage can be observed and
    treated, if present.
    Royal College of Obstetricians and Gynaecologists

    5. Exit techniques
    Wound closure:
    Proper closure of fascia within
    umbilical port site to prevent wound
    dehiscence or hernia
    Avoid hernia risk by closing sheath:
    - Midline port sites > 7mm
    - Lateral port sites > 5 mm

    Royal College of Obstetricians and Gynaecologists

    Now show the Video: Closed


    laparoscopic entry technique

    Now show the video: Alternative


    laparoscopic entry techniques

    Royal College of Obstetricians and Gynaecologists

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