setup ergonomics port placement complications

1. BASICS OF
LAPAROSCOPY
P R E S E N T E R : D R S H R U T H I S H I V D A S
M O D E R A T O R : P R O F D R P A L L A V I V R
D E P T O F G Y N O N C O , K M I O , B ’ L O R E
Dr Shruthi Shivdas

2. CONTENTS
• BASIC SET UP – laparoscopic tower shelf
• ERGONOMICS
• PORT PLACEMENT
• ENTRY
• ENERGY DEVICES
• COMPLICATIONS
• STERILISATION
Dr Shruthi Shivdas

3. LAPAROSOPIC TOWER
The laparoscopic "tower"
Shelf contains
1. Imaging system
2. Insufflator
3. Electrocautery unit
In this manner, the surgeon can
rapidly assess any equipment
problems (eg. loss of
insufflation pressure) for rapid
trouble-shooting.
Electrocautery unit should
ideally be kept separately to
avoid antenna coupling.
Dr Shruthi Shivdas

4. IMAGING SYSTEM
monitor
Camera box
Light Source
Dr Shruthi Shivdas

5. LIGHT SOURCE & CABLE
• Three types of light source are in use today: 1. Halogen light source 2. Xenon light
source 3. Metal halide light source
• Xenon - Best illumination by powerful sources. Minimum heat conduction to the
telescope body- “cold light”
• Light cables transmit the output from the light sources to the telescope.
• 1. Fiber optic cable 2. Liquid crystal gel cable.
• White balance by making sure white is correctly identified so that all the colors through
the spectrum are correct.
Dr Shruthi Shivdas

6. LIGHT CABLE
Dr Shruthi Shivdas

7. TELESCOPE -DIAMETER
• 10mm-Most commonly used for operative as well as Diagnostic
purpose.
• 5mm- Mainly used for diagnostic purpose , can be used for operative
purpose.
• < 5mm- Very delicate MINIlaparoscopy mainly used in children
(1.1mm) Diagnostic purpose also in operative purpose.
• With contemporary technology, 5-mm lenses are useful but provide
slightly less capacity for light transmission and may appear dark. The
darkness of the 5-mm lens may be accentuated by blood in the
operative field as blood further absorbs light.
Dr Shruthi Shivdas

8. TELESCOPE -ANGLES
Straight/forward view with - 0 degree
Angled at -25 to 30 or 45 to 50 degrees.
With a 0 degree lens, the lens is flat and rotating the laparoscope does not
alter the angle of vision; better for panaromic vision. Sufficient for
diagnostic procedures.
Angled lenses provide additional optical versatility by giving the operative
team the ability to look at the surgical field with an angle up to either 30
degrees or 45 degrees by rotating the laparoscope;
Especially useful for viewing underlying areas under difficult anatomical
conditions e g: study of adhesions, ovarian surfaces ,while sealing uterine
vessels, PLND
Dr Shruthi Shivdas

9. ERGONOMICS
Dr Shruthi Shivdas

10. TOWER SHELF- STRAIGHT LINE PRINCIPLE
• The laparoscopic "tower"
should be straight ahead of
the surgeon and in line with
the forearm–instrument
motor axis.
• It should be positioned
lower than the surgeon's eye
level to avoid neck
extension. The most
comfortable viewing
direction is approximately
15° downward.
Dr Shruthi Shivdas

11. TABLE HEIGHT
Proper table height keeps the surgeon's arms and elbows
adducted at his/her side at all times, which makes operating more
comfortable.
This is especially true for intracorporeal suturing where maximum
range of motion is imperative.
Dr Shruthi Shivdas

12. SURGEON’S STANCE
Viewing distance is highly
dependent on monitor size.
Keeping monitor too close leads to
extensive accommodation of the
eyes and contraction by the
extraocular muscles and eye
fatigue.
Keeping it too far leads to staring
and loss of detail, eyestrain.
The distance of the monitor from
the surgeon also impacts
on eyestrain.; preferably between
60 – 80 cm
Dr Shruthi Shivdas

13. THE CAMERA-MAN
• Having the cameraman and the surgeon standing on the
same side of the patient, the surgeon is prevented from
working in "reverse" or at an angle.
• For pelvic laparoscopic procedures,the surgeon typically
stands on the patient's left side and the assistant stands on
the patient's right side
Dr Shruthi Shivdas

14. CORDS & TUBINGS
• To minimize tangling, the surgeon should keep only enough cord length for
each instrument without excess.
• The suction-irrigation tubing, bipolar cautery cord, surgical energy device
cords such as the harmonic scalpel cord or LigaSure cord should run off the
head of the bed away from the surgeon.
• Once the surgical team is pleased with trocar deployment and the access for
surgery, the insufflation tubing should be placed on any trocar other than the
camera trocar, which minimizes its cooling effect and consequent lens
fogging.
Dr Shruthi Shivdas

15. OPERATIVE SETUP
Camera man
TOWER
Dr Shruthi Shivdas

16. Dr Shruthi Shivdas

17. FOOT PEDALS
• Best to use hand controls when
possible.
• Pedals should be placed near the foot
and aligned in the same direction as
the instruments, toward the target
quadrant and laparoscopic monitor,so
that the surgeon need not twist his /
her body or leg.
• A pedal with a built‐in foot rest is
preferable, to avoid the surgeon
having to keep the foot in air in
between activations.
X
Dr Shruthi Shivdas

18. ERGONOMICS
I. SURGEON’S STANCE
1. Straight Line Principle
2. Low Lying Table Below Elbow
3. Gaze Down View
II. PORT POSITIONING
1. Triangulation if ipsilateral
2. Baseball Diamond if contralateral
3. Manipulation Angle
4. Azmuth Angle
5. ElevationAngle
Dr Shruthi Shivdas

19. PORT
POSITIONING
Dr Shruthi Shivdas

20. LATERALITY OF THE LAP SURGEON
CONTRAL ATERAL IPSILATERAL
Dr Shruthi Shivdas
Baseball diamond
Concept/
triangulation
• Triangulation
• Sectorization

21. Dr Shruthi Shivdas

22. POINTS FOR SECONDARY PORTS/WORKING
PORTS (BASEBALL)
STEP 1 : OPTIMAL AREA
• For optimal performance, half to 2/3 of instrument should be
inside abdomen.
• So adult instrument, (36 cm) 28 cm to 24 cm should be inside.
STEP 2 : POINT WITHIN THE AREA
• Telescope mid way between
instruments (contralateral)
• Manipulation angle between
instruments should be 60 degrees
• Approximatel 7-8 cm from
Dr Shruthi Shivdas

23. ANGLES IN CONTRALATERAL
POSITIONING
Dr Shruthi Shivdas

24. Dr Shruthi Shivdas
CAMERA
TARGET
Working Port Working Port
18 cm
24 cm
BASEBALL
DIAMOND
600

25. • Advantages of contralateral port positioning :
1. No magnification errors (instrument closer to camera appears larger)
2. No movement errors (mvt of instrument close amplified)
Disadvantages
1. Surgeon has to bend
2. Ergonomically poor
3. Surgeon’s hands clash with camera
Dr Shruthi Shivdas

26. IPSILATERAL PORT POSITIONING
18- 20 cm
6-8cm
Both can be used in ipsilateral port placement to decide position of secondary working ports (on surgeon
side) and assistant ports, with respect to camera.
Sectorisation used while doing omentectomy and PALND (trans and extraperitoneal).
Camera in RIF; surgeon between pt legs and works on suprapubic and LIF ports.
Sectoring of instruments should be avoided by beginners since it requires a greater degree of understanding
of laparoscopic views and significantly different one-eye coordination; image and mobility parallax errors.
Dr Shruthi Shivdas

27. FOOT end
A
W
W
Dr Shruthi Shivdas
Red marks denotes
adaptations for
transperitoneal PALND

28. EPPALND
Trocar placements for
transperitoneal paraaortic
lymphadenectomy.
Trocar placement for extraperitoneal para-aort
lymphadenectomy.
The initial entry is placed at the umbilicus to evaluate the abdominal cavity.
10-mm camera trocar 2-3 cm medial to the left ASIS
surgeon uses his/her index finger to open the extraperitoneal space between
the peritoneum and muscles of the abdominal wall. A balloon-tipped trocar
is then inserted and used to visualize the extraperitoneal space.
Insufflate the extraperitoneal space while exsufflating the peritoneal cavity at
the same time.
Working ports 1 – 1.5 cm medial to ant axillary line
Assistant port 3 – 5 cm above camera port.
C
W
W
Dr Shruthi Shivdas

29. Leg end
ASIS
S
u
b
c
o
s
t
a
l
Ant Ax Line
CamP
AssP
1 – 1.5 cm
Dr Shruthi Shivdas

30. EPPALND
• As the camera trocar site is usually positioned more medial than the working trocars, the
camera must be angled up to view the operative field. In this position, the camera driver
must hold the laparoscope and camera rather low.
• Allowing the camera driver to sit on a stool optimizes comfort and performance.
Dr Shruthi Shivdas

31. SAFE ENTRY
Dr Shruthi Shivdas

32. • Closed Technique- Verres
• Open Technique- Hassans – Primary Trocar
• Direct Entry with Primary Trocar
Dr Shruthi Shivdas

33. VERESS ENTRY
Dr Shruthi Shivdas
Based on the Cochrane Review (2015),
closed entry associated with
• the risk of failed abdominal entry (8.5–
11.6%)
• extra-peritoneal insufflation (2%)
• omental injury (2%)
UMBILICAL VERESS:
The skin incision should be at the deepest
point of the umbilical pit as this is the point
where all the abdominal wall layers (skin,
fascia and parietal peritoneum) merge and
fuse, and there is an absence of muscles and
subcutaneous fat. This is the thinnest entry
point to the abdomen independent of
patient’s BMI .
The base of the umbilicus or trans-umbilical
insertion is contraindicated in patients with
known or suspected umbilical pathology (e.g.,
adhesions, herniation) or after three failed
attempts to insert the Veress needle

34. PALMER’S POINT
Dr Shruthi Shivdas
• Left upper quadrant (LUQ), also referred as Palmer’s point, is located 3 cm below the left subcostal border
in the mid-clavicular line . (2 – 3 finger widhth lateral to midline, and 3 finger breadth below subcostal line)
• Nearly zero risk of injury to large vessels
 patients with longitudinal peri/infra-umbilical laparotomy scars, obesity
 very thin women with android pelvis and prominent sacral promontory in whom large vessels lie within
2 cm of the umbilicus
 when prominent aortic pulsations are palpated in close proximity to the umbilicus.
 after three failed trans-umbilical attempts.
• The Palmer’s point serves for both Veress needle and primary trocar insertion after abdominal
insufflation .
• Gastric decompression is recommended
• Contraindications for this approach include splenomegaly, hepatomegaly, portal hypertension, gastric or
pancreatic masses, history of a splenic or gastric surgery and presence or suspicion of left upper quadrant
adhesions

35. Dr Shruthi Shivdas
Two clicks SHOULD BE be heard/ felt (resistance), corresponding to the penetration of the abdominal fascia
and parietal peritoneum, respectively.
.
The insertion should be ceased as soon as the abdominal entry is achieved.
Lateral movements of the introduced needle must be avoided, since these may enlarge a puncture
visceral/vascular injury of 1.6 mm to an injury of up to 1 or more cm
Spring loaded
Blunt tip retractable into sharp sheath
Veress Intraperitoneal Pressure (VIP <= 10mm
Hg) is the only one reliable indicator of
correct Veress needle placement.

36. NEEDLE ANGULATION
Dr Shruthi Shivdas
Abd wall elevation always not needed

37. DIRECT ENTRY –PRIMARY TROCAR
• a single blind step without prior pneumo-peritoneum as an alternative to the Veress needle
technique.
• After skin incision, the anterior abdominal wall is elevated by two towel clips or manually,
• Primary trocar should be inserted in the same direction as the Veress needle, in a
controlled, two-handed manner, perpendicular till rectus sheath; angulated at peritoneum.
• The advantage of this method was thought to be avoidance of the complications related to
Veress needle use, including extra-peritoneal insufflation, omental/intestinal insufflation
and CO2 embolism as well as failed pneumo-peritoneum .
• Fastest entry
• The recommended trocars for direct peritoneal entry are to be sharp and pointed to
minimize penetration force .
• The use of both bladeless and bladed optical trocars have been also reported , although the
manufacturers generally recommend the insertion of bladed optical trocars only after
pneumo-peritoneum is established.
Dr Shruthi Shivdas

38. PRIMARY TROCARS
Dr Shruthi Shivdas

39. OPEN ENTRY (HASSAN’S
Dr Shruthi Shivdas
• preferred method for patients with a history of previous
surgeries (i.e., suspected intra-abdominal adhesions) or
after other entry techniques fail .
• The open technique has also been used in pregnant
women, as well as in very thin patients and children who
have short anterior– posterior abdominal diameters.
• The open (Hasson) technique is associated with a reduced
rate of failed abdominal entry, without a significant
difference in visceral or vascular injury rates
• Blunt trocar is introduced, only after visualising omentum
or bowel.
• Currently, blunt-tip trocars with an inflatable balloon are
frequently engaged to ensure airtight fixation (Hassons
canula)

40. OPTICAL TROCAR AND CANNULA
ACCESS (DIRECT VISION) TECHNIQUE
• the peritoneal cavity is approached under direct monitor view, with the
following three specialized optical devises and methods: the reusable
optical Veress needle, the single use optical trocar and cannula, and the
reusable threaded visual cannula
• The single-use optical trocar, with a laparoscope in the hollowed trocar, is
placed into the skin incision (0.5–1cm), perpendicular to the abdominal
wall. Gentle linear pressure is applied while observing the progression of
the device tip through each layer of the abdominal wall. After the
abdominal cavity is reached, the hollowed trocar with the laparoscope is
withdrawn, then the laparoscope reinserted through the cannula .
• The optical trocar (direct vision) entry is not superior to the conventional
open (Veress needle) or closed (Hasson) entry techniques regarding the
risk of iatrogenic injuries (II-2/B).
Dr Shruthi Shivdas

41. OPTICAL TROCAR
Dr Shruthi Shivdas

42. INJURY - PROOFING
• All equipment should be checked, correct connections confirmed and laparotomy instruments
available in case of conversion.
• Camera should be connected and white-balanced before the primary trocar placement.
• Urinary catheter and/or nasogastric tube are placed before laparoscopy since a filled bladder or
stomach increases the risk of iatrogenic injuries. Latter especially in cases where difficult
endotracheal intubation was encountered.
• To avoid displacement of the ‘‘pelvic’’ bowel in a cephalad direction and reduce the risk of
damage to retroperitoneal structures by misdirection of the Veress needle or the primary trocar,
the patients should be horizontal at the time of laparoscopic entry.
• After primary trocar, Inspect the abdomen with the laparoscope. The distal tip of the trocar should
be within the peritoneal cavity. The area immediately under the primary trocar deployment site is
the first place to be inspected for possible Veress needle of trocar injury. There should be no
evidence of trauma such as blood, gastric fluid or urine in the peritoneal cavity. I
Dr Shruthi Shivdas

43. INSUFFLATOR
IAP for primary trocar introduction should be 25 mmHg in healthy women with immediate IAP reduction to
12–16 mmHg after all trocars have been inserted.
This achieves three things: (1) creates a tense splinting effect of the abdominal wall that does not indent
when linear penetration force is applied during trocar insertion, (2) Initial high IAP creates approximately 6
cm distance between the anterior abdominal wall and the underlying intra/retroperitoneal organs/structures
and (3) Reducing pressure after entry avoids compromise venous return .
usual adult abdominal cavity will insufflate with approximately 3 to 5 L of CO2 gas.
During Verres insufflation Initially flow rate is 1-2 L/mte & then increased, preferably to 3-6 L/ min.
Dr Shruthi Shivdas
GASES USED FOR INSUFFLATION: -
Filter room air
-Carbon dioxide- commonly used , has advantages of
being rapidly absorbed by blood, nontoxic, cost effective
and can be used with cautery.
CO2 is being used because same refractive index as air,
doesn’t distort the image and is non combustible.
-Nitrous oxide
-Helium

44. ASSISTANT TROCARS
• insert secondary (ancillary) trocars under direct vision, at a 900 angle (perpendicular) to the
skin/abdominal wall, in a controlled, screwing manner, after Trendelenburg.
• Generally 5mm
• 10 mm port may be used with minimizer; preferred if endobag; or camera position change
anticipated (PALND/Omentectomy)
• Placing working trocars too close to each other causes rolling (instruments rubbing against each
other in side the patient). Specifically, the instruments can contact the camera making ideal
visualization of the surgical field challenging.
• To prevent the physical interaction of the camera with the working trocars, the trocars should be
placed a minimum of 6 cm – 8 cm apart.
• Lateral Trocars should be placed at least 6cm lateral to the midline to prevent epigastric injury.
• A safe and useful site for secondary trocar placement is located on an imaginary line connecting
the umbilicus and the anterior superior iliac crest, approximately 2 cm from the iliac crest
• In the morbidly obese patient, the pannus pushes the peritoneum anteriorly, thereby displacing
the retroperitoneum more laterally. In this patient population, moving the trocar template laterally
is usually required to optimize access and surgical performance.
Dr Shruthi Shivdas

45. AVOIDING INJURY TO IEA
YELLOW ISLAND
Accumulation of adipose subperitoneal tissue that is
at the lateral third of a line between the ASIS and
the umbilicus. There are no major vessels such as
the IEA present in the ‘Yellow Island’.
It is very easy to identify in obese women in whom
the IEA is difficult to locate by laparoscopic
visualisation.
SAFE ZONES:
medially, within 1 cm either side of the midline
2) laterally, more than 8 cm from the midline
IEA can also be directly visualized transperitoneally.
Superficial EA can be visualized by transillumination
Dr Shruthi Shivdas

46. YELLOW ISLAND
Dr Shruthi Shivdas

47. LAPAROSCOPIC
ENERGY
SOURCES
Dr Shruthi Shivdas

48. TRADITIONAL ENERGY DEVICES
• Monopolar energy requires that the current from the
generator pass from the active electrode through the patient
and out of the body through a dispersive electrode pad
(grounding pad) connected to the generator to form a
complete circuit.
• In bipolar energy ,the active electrode and the return
electrode are integrated into the energy delivery instrument
with the target tissue being grasped between to complete
the circuit, sparing the patients body from the
circuit, making bipolar energy more precise,more
haemostatic and less likely to cause collateral damage to
adjacent tissues.
• Disadvantages of bipolar:
– needs increased time for coagulation due to a low power
setting, which leads to charring and tissue adherence with
incidental tearing of adjacent blood vessels.
– the electrodes cannot cut tissue. Even if a continuous (cut)
Dr Shruthi Shivdas

49. GOOD PRACTICE IN
ELECTROSURGERY
MONOPOLAR DEVICES
• Use the lowest possible power setting.
• Use short intermittent activations.
• Allow a safety margin when close to vital
structures because of lateral thermal
spread.
• Avoid activation in close proximity to or
in contact with another metal
instrument.
• Use return electrode monitoring and
active electrode monitoring technology.
BIPOLAR DEVICES
• Avoid tension on the tissue during activation because this
compromises coagulation.
• In areas with anatomical tension, repeat coags with
overlapping of the seal, without leaving any unsealed tissue
in between two seals.
• Keep the jaws of the instrument clean at all times by wiping
with a wet swab to achieve adequate tissue effects.
• To prevent tissue charring, activate the instrument in a short
intermittent manner and release the tissue just before
current flow is terminated at the vapour phase.
• When stuck to tissue, re-approximate the jaws and
reactivate before opening them. The tissue can also be
irrigated with fluid before reactivation.
• Avoid over-compression of grasped tissue to prevent the
bypass effect
• do not include a big bundle of tissue in the jaws of the
instrument for a good seal.
• Consider skeletonising vessels before application to achieve
a good seal.
Dr Shruthi Shivdas

50. ADVANCED BIPOLAR ENERGY DEVICES/VESSEL
SEALERS
• These devices produces a hemostatic seal by applying high current and low voltage, which differs
from the energy used in standard monopolar and bipolar cautery (high voltage and low current).
The system senses uses the end-effector to sense the impedance of the tissues within the jaw, and
adjusts the energy accordingly. Once the impedance monitor detects that the seal is complete, a
brief period of cooling ensues. After the tissue cools and is ready to be divided, the surgeon is
notified by an audible tone.
• The bipolar energy fuses collagen fibers within the vessel wall to produce a translucent seal
• The delivery of electrical energy by the advanced bipolar system is highly pulsatile, allowing for
tissue cooling during activation in an attempt to minimize lateral thermal spread.
• .All advanced bipolar devices are capable of tissue transection with an incorporated cutting
mechanism. The cutting device is most commonly a retractable blade built into the jaws of the
instrument
• Advanced bipolar devices have been approved by FDA to seal vessels up to 7 mm in diameter.
• Currently available advanced bipolar technologies include LigaSure (Covidien, Mansfield, MD, USA),
Starion Tissue Welding system (Sunnyvale, CA, USA),EnSeal (Ethicon Endo-Surgery, Cincinnati, OH,
Dr Shruthi Shivdas

51. ADVANCED BIPOLAR DEVICES
LIGASURE
ADVANCE WITH
MONOPLOAR
TIP
Dr Shruthi Shivdas
ALL work by approximation of vessels walls
along with fibrin formation

52. LIGASURE MARYLAND
Thin curved tip
Dissection capability
Button for one step sealing & cutting
Dr Shruthi Shivdas

53. ULTRASONIC DEVICES
• Work on principle of piezoelectricity (conversion of mechanical energy to
electrical enery.
• Ultrasonic devices have piezoelectric crystals that generate mechanical
vibrations at over 20 kHz (i.e., above the audible range). The high frequency
vibration of tissue molecules generates stress and friction in tissue, which
generates heat and causes protein denaturation.
• Ultrasonic energy sources result in less charring of tissue, less lateral thermal
spread (0-1mm), and less particulate plume ("smoke") that can degrade the
surgeon's vision.
• Also can be used as a dissector, in addition to coagulation and cutting.
Dr Shruthi Shivdas

54. • AVAILABLE INSTRUMENTS
– ETHICON : Initially the prototype Ultracision Harmonic Scalpel was developed for
commercial use, which was approved to seal vessels up to 3 mm in diameter.
– The Harmonic ACE (Ethicon Endo-Surgery) was subsequently developed; with an active jaw
frequency of 55 kHz, and has been approved by FDA to seal vessels up to 5 mm in diameter.
– Harmonic Ace +7 shears FDA approved for 7mm vessel sealing
– COVIDIEN:AutoSonix (Covidien), Sonocision (Covidien)
– SonoSurg (Olympus America, Center Valley, PA, USA).
Dr Shruthi Shivdas
BOTH USE ADAPTIVE TISSUE
TECHNOLOGY

55. ULTRASONIC VESSEL SEALER
•Greater 5 to 7 mm vessel-sealing reliability with higher
burst pressures than LigaSureTM devices
ACTIVE BLADE
Dr Shruthi Shivdas
MIN for minimum power
level (3) vesselsealing
upto 5 ---- coagulation
effect
MAX for maximum pow
er level(5) corresponding
to cutting effect.

56. INTELLIGENT ULTRASONIC ENERGY
Harmonic ACE , ACE + 7 shears ,ENSEAL X1
An advanced ultrasonic algorithm actively monitors the condition of the tissue within the jaws of
the device and allows the system to intelligently sense and respond to changes in patient tissue
conditions.
The system modulates energy delivery based on tissue thickness and tissue type to optimize
vessel sealing and provide for secure and reliable large vessel sealing.
Less time consuming ,and less thermal footprint
Earlier MIN… reassess….MAX
Dr Shruthi Shivdas

57. • Olympus
• This system is a newer innovation wherein ultrasonic and advanced bipolar energies
have been coupled together.
• Using a single multi-functional instrument, the surgeon may simultaneously seal and
cut vessels up to 7 mm in size with minimal thermal spread
HYBRID TECHNOLOGY (THUNDERBEAT)
Dr Shruthi Shivdas

58. ADVANCED ENERGY DEVICES
Energy system time Visibility Operation Op Time Burst pressure
Thermal spread
Thunderbeat Unimpaired visibility Fastest in class
cutting
Highest mean burst pressure
Least lateral thermal spread
LVSS Smoke production affecting
visibility
Slow surgery Moderate mean burst pressure
2 mm lateral thermal spread
HS Mist production affecting
visibility
Slower surgery Lowest mean burst pressure
0-1 mm thermal spread
ALL seal upto maximum 7mm
Dr Shruthi Shivdas

59. ELECTROSURGICAL UNITS
Dr Shruthi Shivdas

60. COMPLICATIONS
IN
LAPAROSCOPY
Dr Shruthi Shivdas

61. VASCULAR INJURIES
• Major vascular injuries (MVIs) are reported in only 0.05% of laparoscopic cases, with a
mortality rate of 8%.
• Approximately 75% of MVIs associated with laparoscopy occur while obtaining access.
The remaining 25% occur during dissection.
Dr Shruthi Shivdas

62. VASCULAR INJURY WITH VERRES
• A VI during access may present as blood aspirated from a Veress needle.
• the needle should not be insufflated as this may cause CO2 embolization
• surgeon should resist the temptation to remove the needle as it can be used to
help identify the site of injury once access has been successfully gained.
• CO2embolization presents as sudden circulatory collapse during access, deep
cyanosis of the head and upper extremities, elevated right heart pressures and
CVP, and a "millwheel" murmur. Treatment involved stopping insufflation and
desufflating the abdomen, placing the patient in the left lateral decubitus
position (right side up) with the head down to trap the CO2 bubble at the apex
of the right ventricle where it is less obstructive, aspirating the CO2 bubble with
a central venous catheter, and cardiopulmonary bypass.
Dr Shruthi Shivdas

63. VASCULAR INJURY WITH TROCAR &
DISSECTION
• ENTRY INJURY present as blood filling a trocar. In this situation the trocar should not be
removed and should not be connected to insufflation. Leaving the trocar in place will
tamponade the injury, and will help the surgeon to identify the site of injury.
– should be treated by an open exploration which is usually best performed via a midline
laparotomy incision.
– Proximal and distal vascular control should be obtained, and then the trocar can be removed
and the vessel can be repaired.
• DISSECTION INJURY : If the patient is hemodynamically stable, the surgeon can attempt
to manage the situation laparoscopically, conversion to an open procedure is not
mandatory. Dr Shruthi Shivdas

64. HAEMATOMAS
• A VI may also present more subtly.
• A retroperitoneal or mesenteric hematoma may be the only
sign of the injury.
– Examine the course of large vessels.
– Overlying peritoneum is opened with laproscopic scissors or a CO2
laser.
– Hematoma evacuated by alternate suction and irrigation.
– Laprotomy is required if hematoma is expanding or persistent
bleeding
Dr Shruthi Shivdas

65. IEA INJURY
Dr Shruthi Shivdas
As the trocar may tamponade bleeding, it is imperative
to remove trocars under direct vision and low
insufflation pressure.
• a figure-of-eight percutaneous transabdominal
suture may be placed cranially and caudally over the
vessels utilizing a Carter-Thompson or other type of
closing tool (Cobblers needle).However, delayed
suture removal (where the suture was left in place for
72–96 h) may result in cutaneous and abdominal wall
necrosis.
• Tamponade can be achieved by inserting a 14 F
Foley catheter through the cannula, then inflating the
balloon with 15–30 mL of normal saline after
removing the cannula. The balloon is pulled up
against the abdominal wall to produce pressure on
the bleeding vessel. The tamponade can be
sustained by clamping the catheter close to the
abdominal wall using an artery forceps. The catheter
can be left in situ for 24 hours

66. BOWEL INJURY
• bowel injuries are reported in 0.13 – 0.9% of laparoscopic cases. 50% of bowel injuries are caused
by cautery.
• The majority (67%) of bowel injuries are not recognized intra-operatively.
• Most bowel injuries due to a Veress needle can be managed with a single suture if the injury is
recognized immediately. Foul smelling gas through needle is a helpful diagnostic sign. • There may
be GI contents at the tip of needle.
• A trocar injury to the bowel requires formal repair.
• A thermal injury to the bowel may be treated with interrupted sutures if the lesion is not full
thickness. However, these patients should be followed post-operatively very carefully and should
be observed for a prolonged period of time as energy-based injuries may result in delayed
perforation of the bowels.
• Full thickness bowel injuries should be treated with resection and formal repair.
• Bowel injuries that are recognized post-operatively present quite differently than the traditional
presentation that is typical perforated viscous. Single trocar-site pain, abdominal distention,
diarrhea and leukopenia are the presenting symptoms.
Dr Shruthi Shivdas

67. AVOIDING BOWEL INJURY WITH SUCTION
CANULA AT SECONDARY PORTS
Dr Shruthi Shivdas

68. MANAGEMENT OF STOMACH INJURY
• • Extend trocar incision into a minilap. for a two layer closure.
• • Laparosocpically - Purse string suture or a figure of 8 suture in the seromuscular layer
surround the defect.
• - Nasogastric tube drainage for few days.
• In palmers point, Lee Hung opint and prolonged mask ventilation, NGT to be inserted.
Dr Shruthi Shivdas

69. UROLOGICAL INJURY
• Bladder - Injury caused by accessory trocar usually .
• Diagnosis : Appearance of gas and blood in Foley’s catheter bag.
• Management – - If defect is larger. • Repaired by a figure of 8 suture through
muscularis of bladder & second suture to close peritoneum
• Place an indwelling catheter for 7-10 days and prophylactic antibiotics
Ureter - May be injured in adenexal surgeries.
• Thermal injury will result in ureteral narrowing and hydroureter. Management – •
Placement of ureteric stent for 3 – 6 weeks
Dr Shruthi Shivdas

70. STERILISATION
OF LAPAROSOPIC
INSTRUMENTS
Dr Shruthi Shivdas

71. • CDC recommends Sterilisation or High Level Disinfection
• Pre sterilisarion HLD Steps involved
– 1. Dismantling- To remove debris from crevices
– 2. Decontamination- visible blood & tissue is wiped off, then soaked
in 0.5% chlorine for 10 minutes
– 3. Pre-cleaning- with an enzymatic product viz. protease
recommended
– 4. Cleaning- with soft brush, detergent & water
– 5. Rinsing- under running water
– 6. Drying
Dr Shruthi Shivdas

72. • STERILIZATION
– a) Steam Sterilisation- Autoclaving at 134° for 30 minutes All insulated instruments,
tubings, cords should be doubly wrapped in cloth
– b) Ethylene Oxide Gas Sterilisation- Non-corrosive to optics Permeates porous
material
– c) Low Temperature Plasma Sterilizer heat & moisture sensitive equipment 25-
50min cycle Keep the instrument in it after plastic covering
• High Level Disinfection with 2% Glutaraldehyde (Cidex Plus) for 20-30 minutes
• Good alternative to sterilisation in case of telescopes, and fibreoptic light cords; as
easily damaged
• The length of time that commercially available glutaraldehyde solutions may be used
varies, usually from 14-30 days. It ought to be tested daily with the manufacturer’s test
strip
• Solutions should be replaced any time they become cloudy
•
• Use of sterile drapes over camera and cord is another alternative, to save time
Dr Shruthi Shivdas

73. • THANK YOU
Dr Shruthi Shivdas