Access and position

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Access and position

  1. 1. James  Bentley  
  2. 2. ¡  Safety  for  the  patient   ¡  Comfort  for  the  surgeon  and  assistants   ¡  Access  to  perform  surgery  
  3. 3. ¡  Avoid  Neurologic  Injury   ¡  Peripheral  Neurologic  Injury   §  inappropriate  positioning  of  the  patient   §  pressure  exerted  by  surgeon/assistants   §  rarely  happens  from  surgical  dissection   (exception  is  obturator  and  genitofemoral  nerve  injury   with  increasing  retroperitoneal  dissections)  
  4. 4. ¡  Arms  tucked  at  both  sides   ¡  Table  Height-­‐-­‐usually  best  if  lowered   completely  (18  inched)   ¡  Monitor  Placement   §  2  monitors-­‐-­‐one  on  each  side,  both  distal  to  the   patient s  waist  so  directions  are  not  opposite   §  1  monitor-­‐-­‐between  patient s  legs  so  surgeon  or   assistant  do  not  have  to  strain  their  necks  
  5. 5. ¡ Primary  Trocar   ¡ Accessory  Trocars  
  6. 6. ¡  Veres  Needle   ¡  Direct  Trocar  Insertion   ¡  Open  Laparoscopy  with  Hasson  
  7. 7. Open Laparoscopy With Hasson Trocar
  8. 8. ¡  Probable  decreased  risk  of  perforation  of   visceral  organs     §  small  bowel,  colon,  stomach,  bladder,  ureter,   uterus   ¡  If  bowel  laceration  occurs,  can  be   recognized  and  repaired  at  same   operation   §  10,840  open  laparoscopies  by  18  Obs/Gyn   §  6  bowel  lacerations,  4  of  these  recognized   and  repaired  at  the  same  surgery  
  9. 9. ¡  Probable  decreased  risk  of  CO2  embolus     §  gas  embolus  1/10,000  procedures   §  can  occur  from  accidental  intravascular   injection  of  CO2  during  insufflation  through  a   misplaced  Veres  needle   ¡  Less  risk  of  other  inappropriate  gas   insufflations  (e.g.  preperitoneal  or   omental)   ¡  Decreased  costs  of  sharpening  Veres   Needle  and  Trocars  
  10. 10. ¡  May  be  slightly  safer  in  patients  who  have   had  prior  abdominal  surgery     ¡  Relatively  easy  for  Gynaecologists  to  learn   because  dissection  similar  to  Post-­‐Partum   Tubal  Ligations  
  11. 11. ¡  Usually  takes  about  5-­‐10  minutes  longer   than  closed  laparoscopy   ¡  Requires  a  few  more  instruments  (scissors,   haemostats,  sutures,  needle  driver,   retractors)   ¡  Possibly  slightly  larger  umbilical  skin   incision   ¡  Consequently  slightly  higher  risk  CO2  leak   (high  flow  insufflator  may  help)  
  12. 12. Direct Trocar Insertion
  13. 13. ¡  How   §  elevate  and  stabilize  anterior  abdominal  wall   §  control  of  trocar  as  it  penetrates  each  layer  of   anterior  abdominal  wall   §  remove  trocar  and  look  with  laparoscope   ▪  glistening  wet appearance-­‐-­‐intraperitoneal   ▪  dry white  appearance-­‐-­‐extraperitoneal  
  14. 14. ¡  Advantages   §  reduces  number  of   blind procedures   §  decreased  operating  time   ¡  Disadvantages   §  similar  risks  of  viscus  and  vascular   injuries  
  15. 15. ¡  Veres  Needle   ¡  Direct  Trocar  Insertion   ¡  Open  Laparoscopy  with  Hasson  
  16. 16. Preperitoneal Insufflation: Management?
  17. 17. ¡  The  closer  your  skin  incision  is  to  the  center   of  the  umbilicus,  the  lesser  the  chance  
  18. 18. ¡  Remove  Veres,  try  to  drain  CO2,  and   consider  another  site  for  Veres  Needle   insertion   §  suprapubic  approach   §  left  sub-­‐costal  margin  in  mid-­‐clavicular  line   §  transvaginal  approach  via  posterior  fornix   §  transcervical  through  the  uterine  fundus  
  19. 19. ¡  Always  insert  these  under  direct   vision   ¡  Try  to  avoid  the  inferior  epigastric   artery  and  vein  
  20. 20. ¡  Trans-­‐illumination  (no  help  in    obese)     ¡  Lateral  to  obliterated  umbilical   ligaments   ¡  With  index  finger,  apply  pressure  over   proposed  site  of  entry   §  ensuring  away  from  inferior  epigastrics,   adhesions,  or  other  vital  structures   ¡  Insert  trocar  perpendicular  (not  angled)   to  abdominal  wall  
  21. 21. ¡  Surgeon’s  responsibility  to  perform   operative  laparoscopy  safely  and   effectively     ¡  Requires  greater  time  and  attention  to   details  such  as  positioning,  access,  and   equipment  

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