Achim Schneider and Co Workers from University of Jena and Charite Berlin developed these Golden Rules over a time period of more than 20 years. This approach enables sophisticated laparoscopic procedures with best outcome for patients affected.

1. Golden Rules of Laparoscopy
by Professor Achim Schneider
Dr Dirk Grothuesmann
http://dg-maternalhealth.de/

2. Frustration Alert
• Do not get overwhelmed by Number of Rules
• Study and apply them Step by Step
• Review them regularly
• Even your Teacher will violate them sometimes
• Add your own Rules if feasible

3. General Surgery
• Anatomic Rule Know them by Heart
• Obedience Rule Stick to the Rules
• No progress Rule Call for Help in Time
• Identical mistake Rule Do not repeat the same Mistake
• Communication Rule Inform the Patient and the Family
• Truth Rule Be honest, also to Yourself

4. Anatomy

5. Anatomy Rule
Anatomy is identically all over the World
• Know the Anatomy by Heart
• You must know which anatomy Structure to preserve
• You must know which Structure you can transect, sacrifice or remove
• You must know which anatomical Variations you may run into and
how to handle them

6. Bicycling is identically all over the World
So make it Safe for All
Anatomy is identically all over the World
So make Surgery Safe for All

7. Obedience Rule
Stick to Rules
• Follow the Rules rigorously to avoid Accidents
• Do not modify Rules unless proved otherwise

8. Time

9. No Progress Rule
Call for Help in a timely Fashion
• When there is no Progress in a Operation for more than 15 minutes
call for help

11. Identical Mistake Rule
Do not repeat the same Mistake
• Every Surgeon makes Mistakes
• A good Surgeon does not repeat the same Mistake

12. Communication Rule

13. Communication Rule
Inform the Patient and her Family
• Always inform the Patient’s Family in the preoperative counselling
• Always inform the Family directly after the Operation about its Course

14. Truth Rule

15. Truth Rule
Be honest, also to Yourself
Ernst Ferdinand Sauerbruch (3 July 1875 – 2 July 1951)
• A bad Outcome is finally the Surgeons own Responsibility
• This Burden gets bearable through careful Diagnosis, adequate Skills and
mindful Self-Awareness
• Best Basis is the Truth
• The Surgeon who tries to find Excuses for his Failure, disregards the most
valuable Rule of his Guild

16. General – Laparoscopy
• Orientation Rule Optimal Orientation
• Visibility Rule Obtain good Imaging
• Information Rule Get close or pull away
• Overview Rule Get the maximal Overview
• Peek out Rule Never hold the Optic to far inside
the Trocar
• Action Rule In the Center of the Monitor

17. General – Laparoscopy
• Golden Eye Rule Look always only at the Monitor
• Two Hands Rule Use both Hands
• Interaction Rule Support Progress in the operation Activity
• Alignment Rule Do not cross Instruments
• Rocking Ship Rule Keep it steadily
• Winning Position Rule Never change a winning Position
• Review Rule Watch your own Videos

18. Orientation Rule

19. Orientation Rule
Optimal orientation
• Orientation of Optic and Objects must match
• The Optic should be held always in the correct Orientation
• 12 o’clock on Screen is although 12 o’ clock on Screen
• Stick to the way God created us
• Water is always horizontal

20. Orientation Rule

22. Visibility Rule
Obtain good Image quality
• The Image must always be clear and in focus
• The Optic should always be clean
• Heating the Optic provides sharp and clear Image quality
• Coagulation generates smoke unintentionally, thus the Optic should
be not to close to the Object
• Insufflate warm CO2

23. Visibility Rule

24. Visibility Rule
Foccus
• You can not depend on your Eyes when your Imagination is out of the
focus
(Mark Train, November 30, 1835 – April 21, 1910)

25. Visibility Rule

26. Information Rule
Get close or pull away
• The imagine size should be optimal
• Vary the Distance between Optic and Object for the optimal View
• For Details move the Optic closer to the Object and magnify
• To have an Overview move the Optic away form the Object

27. Information Rule

28. Overview Rule
Get the maximal Overview
• The optic Trocar should be always in line with the abdominal Wall
• If the Trocar is to deep inside the abdominal Cavity you are too close
to the Object and you will not get an Overview

29. Overview Rule
Correct

30. Overview Rule
False

31. Overview Rule
Get the maximal Overview
• Get the small Bowel out of the Pelvis
• Transect adhesions which block Exposure

33. Peek out Rule
Never hold the Optic to far inside the Trocar
• You should not see inside of Trocar but have complete Vision of your
Object

35. Action Rule

36. Action Rule
In the Center of Monitor
• The Action has to be in the Center
• Hold the Camera as if you are the Surgeon

37. Golden Eye Rule

38. Golden Eye Rule
Look always at the Monitor
• The Assistant holding the Camera must always look at the Monitor
• “You are our Eye”
• Never look down
• Instruments are always and exclusively changed by the Nurse

39. Two Hands Rule
Use both Hands
• Use both Hands to manipulate one Instrument is each Hand
• Assistant holds the Optic with the left Hand and Instrument in the
right Hand
• The Surgeon uses always two Instruments, one in each Hand
• Sleeping Hands are Forbidden

41. Two Hands Rule

42. Interaction Rule
Support the Progress in the Surgery
interactively
• The Surgeon must interact
• There are always two Surgeons which interact and cooperate
• Interact actively with the other Surgeon and replace Instruments
when needed

43. Alignment Rule
Do not cross Instruments
• Keep Instruments parallel to each other
• Place Trocars far form each other

44. Rocking Ship Rule
Keep it steadily
• Optic and Instruments must be kept steadily
• All Movements should be controlled
• Do not make hectic Movements neither with the Instruments now
with the Optic
• You are not operating on a Ship
• Hold the Optic steady

46. Winning Position Rule
Never change a winning Position
• The Position of Optic and Instruments should be not changed if not
required
• Do not make unnecessarily Changes when you are in a good Position

47. Review Rule
Watch your own Videos
• Review your own Videos when you have normal adrenalin Level
• Watch Videos of your Coworkers and other Surgeons whenever
possible

48. Technique
• Bladder Rule Bladder filling and emptying
• Support Rule use Belts and Shoulder support
• Size of Incision Rule smaller than Trocar
• Careful Entry Rule shift first Entrance site to left subcostal Side
• Arrogance Rule never be to arrogant for an additional Trocar
• Optic Trocar insert Rule always insert vertically BUT
• Water and Bridge Rule know how to identify the Ureter Rule
• No Blood Rule apply preventive Coagulation
• Clean bipolar Rule always have a clean Bipolar
• Insertion of big Needle Rule every Needle can be inserted
• Reentry Rule use 5 mm Trocars and blunt Instrument

49. Bladder Rule
Bladder filling and emptying Rule
• Use System in order to fill and empty the Bladder

51. Support Rule
Use a Shoulder and Belt Supports
• Use strapping Belts and Shoulder Support in order to prevent sliding
in deep Trendelburg Position
• Do not leave the Patient for more than 3 Hours in the same Position
Beware Compartment Syndrome

53. Size of Incision Rule
Size of Incision must be smaller than the
Diameter of the Trocar
• This will prevent slipping of Trocar
• You can even omit Incision using a conical Trocar

54. Careful Entry Rule
Shift first Entry side to left subcostal Region
in Case of
• Midline Incision by previous Laparotomy
• Previous unsuccessful Attempts through Umbilicus
• Preperitoneal Insufflation
• Pregnancy above 12 Week of Gestation
• History of Radiotherapy

56. Arrogance Rule
Never be to arrogance for an additional
Trocar
• You may need additional Trocars and Instruments
• In obese Patients
• For save Dissection of Adhesions
• In Pregnancy

58. Optic Trocar insert Rule
Insert vertically is most save BUT

59. Water and Bridge Rule
Identify the Ureter
• The Water (Ureter) runs always under the Bridge (A. uterina)
• The Ureter is best identified at the Bifurcation of the common Iliac
Artery

61. No Blood Rule
Support the “Sahara principle”
• Apply preventive Coagulation
• Only by preventive Coagulation anatomic Operation is possible
• Bleeding is the Enemy of the Surgeon
• Avoid using Suction Device during Surgery
• This will force you to avoid Bleeding
• There should be no Bleeding during and at the End of Operation

62. Clean Bipolar Rule
Always have a clean Bipolar
• Only a clean Bipolar can work
• To save Time keep a second Instrument ready

63. Insertion of big Needle Rule
Every Needle can be inserted
• Use big Needle for Metroplasty
• Pull Needle though abdominal Wall

64. Holding Suture Rule
Through Peritoneum, through Uterus
• Holding Suture
• Through Peritoneum for retroperitoneal Dissection
• Through Uterus for Exploration of Pouch of Douglas

65. Reentry Rule
Use a 5 mm Trocar
• When a 12 mm Trocar has to be removed and must be reinserted
• For Reestablishment of Pneumoperitoneum use a 5 mm Trocar for
• Use blunt Instrument rather than Mandrin of Trocar
• To re-insert Trocars use blunt Instruments
• For 10 mm Trocar a sponge-holding Forceps is feasible

66. Contamination Rule
Avoid Contamination of Trocar sides
• Use Endo-Bag or cut finger Glove
• Change Glove after handling Tumor

67. Faszia closing Rule
• Close Fascia Defects > 10 mm or any Trocar Side which became
widened during Surgery

68. Complications
• Get better Rule Patient conditions improve constantly
• Collateral damage Rule avoid thermal Injury
• Stay cool, be prepared Rule always be ready
• Stay cool, be prepared Rule maintain Traction
• Marketing Rule mark the Injury Side
• Never say never Rule be suspicious about additional Injury

70. Get better Rule
Patient Condition improves constantly
• Postoperatively the Patient gets better every Day
• If not generously indicate Re-Laparoscopy in order to exclude
Complications (e.g. Leakage of Bowel, Bladder, Ureter or Bleeding)

72. Collateral Damage Rule
Avoid thermal Injury Rule
• Do not use Coagulation to close Bowel, Bladder, Ureter or Nerves
• Make sharp Dissection close to these Structures and avoid
Coagulation

75. Stay Cool, Be Prepared Rule
Know anatomic Variations
• Be aware about 30% anatomic Variations and vascular Anomalies in
up to 30% of the Patients
• Remember older Women have more fragile Veins than younger
Women

78. What is really needed?
NOT MUCH!

79. Stay Cool Be Prepared Rule
Always be ready
• Always keep these Instruments ready
• Suction
• Bipolar Forceps
• Alligator Forceps
• Clip Applicator

80. Stay Cool, Do Not Panic Rule
Make Compression and wait
• Small Bleedings can be managed by Compression for a few Minutes
and, if necessary, careful bipolar Coagulation

81. Stay Cool, Do Not Panic Rule
Use Suction
• Coagulation in a Pool of Blood is impossible
• Use Coagulation and Suction in a heavy Bleeding

82. Stay Cool, Do Not Panic Rule
Maintain Traction
• Do not PANIC and do not release TENSION when it is Bleeding, rather
make TRACTION
• Traction by Alligator Schneider Forceps reduces Blood flow effectively

84. Stay Cool, Do Not Panic Rule
Use Clips for large Vessels
• Bleeders larger than 2 mm are managed by Clipping

85. Marking Rule
Mark the Injury Side
• Immediately Mark the Injury Side by Suture on the Intestine
• Finding the Lesion on later might be impossible

88. Never Say Never Rule
Be suspicious about additional Injury
• Exclude an additional Injury Side in the event of Injury to Bowel,
Bladder, Ureter
• Never be 100% sure that no other Injury has happened
• One Hole necessitates Exclusion of another Hole

89. Special Procedures
Lymphadenectomy
• Spider Web Rule follow the Spider Web
• Friendly Terrain Rule have no Fear of the Retroperitoneum
• Pulling Rule use no Scissors for Lymphadenectomy
• En bloc Rule do not violate oncologic Safety
• Walk the line Rule walk form one Lymph Node to the next

91. Spider Web Rule
Follow the Spider Net
• Dissection follows the natural Planes and Structures
• Let the CO2 Gas let its work

92. Spider Web Rule

93. Friendly Terrain Rule
Have no Fear of the Retroperitoneum
• The Retroperitoneum is the key to anatomical Surgery
• The Retroperitoneum is your Friend
• Always preserve the anatomical Structures of the Retroperitoneum
• Open the Retroperitoneum far lateral from the infundibulopelvic
Ligament to prevent Bleeding from injured Veins

95. Pulling Rule
Use no Scissors for Lymphadenectomy
• Lymph Vessels and small Blood Vessels can be torn after Coagulation
• Nerves and major Blood Vessels can not be torn and are protected
using this Technique

97. En Bloc Rule
• Do not violate oncologic Safety
• Dissect Lymph Nodes en Bloc with Capsule intact

99. Walk The Line Rule
Walk from one Lymphnode to the next
• The surgical strategy of Lymphonodectomy is easy: the Lymphnode
shows the Way

100. Radical Hysterectomy and Trachelectomy
Rule
• Vaginal Cuff Rule close the Cuff and Vault tight
• Landmark Rule follow the anatomic Nerves
• Raw Egg Rule be careful with Ureter and Bladder

102. Landmark Rule
• Follow the automomic Nerves
• Identify the Hypogastric Nerves and Pelvic Structures
• Never go lateral to these Structures

106. Raw Egg Rule
Be careful with Bladder and Ureter
• Ureter and Bladder are always jeopardized
• Noli me tangere

108. Suture Rule
Adequate Suture will secure Success
• Use always a big Needle
• Always hold the Knot tight prior to the second Knot
• For Metroplasty of big defects apply additional Stiches for Safety

110. Morcellation Rule
Morcellate only benign Fibroids
• If in doubt:
• Enucleate bluntly without touching the Myoma
• Morcellate in Endobag via Mini-Laparotomy
• If Patient is no longer seeking Parenthood advice for Hysterectomy
and morcellate Specimen in Endobag

111. Rectovaginal Endometriosis
• Assessment Rule
• Resection Rule
• Nerve-sparing Rule

113. Assessment Rule
Extent of Disease is assessed intraoperatively
Disease is diagnosed by:
• Rectovaginal Examination
• Transvaginal Dissection
• Laparoscopic Evaluation
Imaging Techniques are inaccurate

116. Resection Rule
•Only anterior rectal Wall is involved
• Resection of Bowel Tube is sufficient
• Mesorectum is not resected
• Hand sutured Anastomosis is save

117. Nerve Sparing Rule
Autonomic Nerves must be spared
• Identify Splanchnic and Hypogastric Nerves
• If invaded by Enometriosis they may be sacrificed unilateral never
bilaterally

118. LEEP Rules
• LEEP excision Rule LEEP Excision under Magnification
• Squamo-culmnar Junction Rule always Identify the Junction
• Archimedes Rule always measure the Conus
• Contact bleeding Rule always take a Biopsy

119. LEEP Rules
LEEP Excision under Magnification
• Identify the Lesion to be removed
• Minimize the Tissue Damage

122. Squamo-Columnar Junction Rule
Always identify SCJ
• Identify Type of Transformation Zone
• Use Endocervicoscopy in T-Zone Type III

124. Achimedes Rule
• Measure Volume of Cone
• Determine the Volume removed

125. Contact Bleeding Rule
Always take a Biopsy
• Do not rely on Cytology or Colposcopy
• No Destruction without prior Biopsy
for Histopathology

127. Acknowledgement
Thanks to the great and inspiring work of
Professor Achim Schneider and his team,
who have developed these Golden Rules
by a dedicated work of more than
20 years of gynecology surgery
Source:
http://www.mvz-fuerstenberg-karree.de/mediathek/

128. Aim of my Project
Dr. Dirk Grothuesmann Consultancy
Improving Maternal Health and Gynecology Services by Training Health Care
Providers: Relaying on standardized training modules I teach evidence-based
obstetrical procedures, gynecology surgery and related evaluation tools to local
personnel in developed and developing countries. Completing the programs
offered, skills gained enable to serve women in need in any requested setting.
http://dg-maternalhealth.de/index2.html

129. http://dg-maternalhealth.de/
Dr Dirk Grothuesmann Consultancy