This document discusses various practical problems that can arise during laparoscopic surgeries and provides solutions to address them. It covers issues related to equipment, anesthesia, vision, suction/irrigation, expertise development, tissue retrieval, and more. The key challenges include ensuring proper OR setup and equipment functioning, developing hand-eye coordination, managing intraoperative bleeding, and selecting appropriate techniques for conditions like large uteri or adhesions. Attention to details and readiness to address technical issues are emphasized to help surgeons overcome challenges that come with new procedures.

1. PRACTICAL PROBLEMS INPRACTICAL PROBLEMS IN
LAPAROSCOPYLAPAROSCOPY
By Dr. RAMESH .BBy Dr. RAMESH .B

2. Anesthesia Problems
Equipment Problems
Electro Surgery
Problems
Expertise Problems
Cost
Problems
Inadequate Team
Antagonism
Inexperienced
Assistant
Problems of
Disposing
Disposables
Power Supply
Problems
OR Setup
Problems
Practical Problems

3. IntroductionIntroduction
 Operative laparoscopy is an evolving field andOperative laparoscopy is an evolving field and
surgeons are new to this field and are still in thesurgeons are new to this field and are still in the
process of acquiring and polishing their surgicalprocess of acquiring and polishing their surgical
skills. Anything new poses challenging problemsskills. Anything new poses challenging problems
and only time and experience can help oneand only time and experience can help one
overcome them.overcome them.

4. OR Set Up

5. 
Equipment Problems

6.  LaparoscopicLaparoscopic
EquipmentEquipment
1.1. Assure table tilt mechanism isAssure table tilt mechanism is
functional.functional.
2.2. Consider using shoulder braceConsider using shoulder brace
and extra safety strap.and extra safety strap.
3.3. Assure availability of FoleyAssure availability of Foley
catheter and N/G tube.catheter and N/G tube.
Preoperative ConsiderationsPreoperative Considerations

7. 4.4. Assure all power sources areAssure all power sources are
connected and appropriate unitsconnected and appropriate units
are switched "on" (Don’t useare switched "on" (Don’t use
multi-socket single source or themulti-socket single source or the
circuit will overload).circuit will overload).
5.5. Assure adequate volume ofAssure adequate volume of
compressed gas (at insufflator andcompressed gas (at insufflator and
pressure irrigator). Backup fullpressure irrigator). Backup full
tank must be available.tank must be available.

8. 6.6. Assure insufflatorAssure insufflator
alarm is setalarm is set
appropriately. Assureappropriately. Assure
tight connectiontight connection
between insufflatorbetween insufflator
tubing and Luer-locktubing and Luer-lock
adapter.adapter.
7.7. Assure full volume inAssure full volume in
irrigation fluidirrigation fluid
container (recheckcontainer (recheck
during case).during case).

9. 8.8. Check the electrosurgical unit;Check the electrosurgical unit;
make sure auditory alarm ofmake sure auditory alarm of
machine is functioningmachine is functioning
properly and the groundingproperly and the grounding
pad is appropriate for thepad is appropriate for the
patient.patient.
9.9. Check Veress needle forCheck Veress needle for
proper plunger/spring actionproper plunger/spring action
and assure easy flushingand assure easy flushing
through stopcock and/orthrough stopcock and/or
needle channel.needle channel.
10.10. Assure closed stopcocks on allAssure closed stopcocks on all
ports.ports.

10. Excessive Pressure
Required for Insufflations
 Veress needleVeress needle
or cannula tipor cannula tip
not in freenot in free
peritonealperitoneal
cavitycavity
 Reinsert needleReinsert needle
or cannulaor cannula

11.  Veress is inside, but gasVeress is inside, but gas
is not flowing andis not flowing and
pressure is high-pressure is high-
may be a piece ofmay be a piece of
omentum is stuck –omentum is stuck –
shake the abdominalshake the abdominal
wall and withdraw thewall and withdraw the
needleneedle
 maybe the Veress is notmaybe the Veress is not
patent- flush it withpatent- flush it with
saline to clear thesaline to clear the
channel.channel.

12.  Occlusion ofOcclusion of
tubing (kinking,tubing (kinking,
table joints, etc.)table joints, etc.)
 Port stopcockPort stopcock
turned offturned off
 Patient is “light”Patient is “light”
 Inspect full length ofInspect full length of
tubing. Replace withtubing. Replace with
proper size asproper size as
necessarynecessary
Fully open stopcockFully open stopcock
 Give more muscleGive more muscle
relaxantrelaxant

13. Loss ofLoss of
PneumoperitoneumPneumoperitoneum
 CO2 tank emptyCO2 tank empty
 Accessory portAccessory port
stopcock(s) notstopcock(s) not
properly adjustedproperly adjusted
 Leak in sealing capLeak in sealing cap
or stopcockor stopcock
 ExcessiveExcessive
suctioningsuctioning
 Change tankChange tank
 Inspect allInspect all
accessory ports.accessory ports.
Open or closeOpen or close
stopcock(s) asstopcock(s) as
neededneeded
 Change cap orChange cap or
cannulacannula
 Allow time toAllow time to
reinsufflatereinsufflate

14.  TightenTighten
connectionsconnections
 Replace orReplace or
secure suturessecure sutures
 ConnectConnect
tubingtubing
 Adjust flowAdjust flow
raterate
 Loose connection ofLoose connection of
insufflator tubing atinsufflator tubing at
source or at portsource or at port
 Hasson stay suturesHasson stay sutures
looseloose
 TubingTubing
disconnection fromdisconnection from
insufflatorinsufflator
 Flow rate set too lowFlow rate set too low

15. EntryEntry
 2)- Trocar- if the2)- Trocar- if the
pneumoperitoneumpneumoperitoneum
is lost prior tois lost prior to
insertion due to ainsertion due to a
deep incision-deep incision-
 Close the siteClose the site
with Allis, createwith Allis, create
pneumoperitonepneumoperitone
um from aum from a
different point,different point,
preferablypreferably
Palmar’s andPalmar’s and
introduce trocarintroduce trocar
from thefrom the
primary site.primary site.

16.  3)-Frequent slipping3)-Frequent slipping
of 5mm trocars -of 5mm trocars -
use a threaded cannulause a threaded cannula
If extraperitonealIf extraperitoneal
insufflation occurs,insufflation occurs,
EntryEntry
let the gas escape and gainlet the gas escape and gain
entry from the Palmar’ sentry from the Palmar’ s
point which is a safepoint which is a safe
alternative. This point ofalternative. This point of
insertion is also safe in ainsertion is also safe in a
patient with multiplepatient with multiple
abdominal incisionsabdominal incisions

17. PositionPosition
 Position yourself well and the table must be at the level of yourPosition yourself well and the table must be at the level of your
elbow to ease the strain on the shoulder muscles.elbow to ease the strain on the shoulder muscles.
 Position the patient well for vaginal manipulation and freePosition the patient well for vaginal manipulation and free
range of movements.range of movements.

18. VisionVision
 1)Halogen lamp1)Halogen lamp
gives a yellow hue-gives a yellow hue-
 2) Hazy picture-–to2) Hazy picture-–to
prevent a hazyprevent a hazy
picturepicture
 3) frequent fogging3) frequent fogging
 get used to it or switchget used to it or switch
over to Xenonover to Xenon
Focus your scopeFocus your scope
prior to entry andprior to entry and
properly clean the lensproperly clean the lens
and the camera headand the camera head
fogging-clean the tipfogging-clean the tip
with Betadine / hotwith Betadine / hot
salinesaline..

19. VisionVision

4)If the blood and4)If the blood and
debris aredebris are
persistently irritatingpersistently irritating

TIP-3 chip digitalTIP-3 chip digital
camera gives a verycamera gives a very
good vision and agood vision and a
smooth picture. Asmooth picture. A
medical monitormedical monitor
prevents eye strainprevents eye strain

Flush the primaryFlush the primary
trocar to clear anytrocar to clear any
trickling bloodtrickling blood
from the insertionfrom the insertion
site and thensite and then
touch the tip of thetouch the tip of the
laparoscope withlaparoscope with
irrigating fluid onirrigating fluid on
a clean surfacea clean surface

20.  Loose connectionLoose connection
at source or scopeat source or scope
 Bulb is burnedBulb is burned
outout
 Fiber optics areFiber optics are
damageddamaged
 AdjustAdjust
connectorconnector
 Replace bulbReplace bulb
 Replace lightReplace light
cablecable

21. VisionVision
 Automatic irisAutomatic iris
adjusting to brightadjusting to bright
reflection fromreflection from
instrumentinstrument
 Monitor brightnessMonitor brightness
turned downturned down
 Room brightnessRoom brightness
floods monitorsfloods monitors
 Re-positionRe-position
instruments,instruments,
Readjust settingReadjust setting
 Dim room lightsDim room lights

22.  Camera control orCamera control or
other componentsother components
(V.C.R., printer,(V.C.R., printer,
light source,light source,
monitor) not “on”monitor) not “on”
 Cable connectorCable connector
between camerabetween camera
control unitcontrol unit
and/or monitorsand/or monitors
not attachednot attached
properlyproperly
 Make sure all powerMake sure all power
sources are pluggedsources are plugged
in and turned onin and turned on
 Cable should runCable should run
from “video out” onfrom “video out” on
camera control unit tocamera control unit to
“video in” on primary“video in” on primary
monitor. Usemonitor. Use
compatible cables forcompatible cables for
camera unit and lightcamera unit and light
source.source.
VISIONVISION

23. foggingfogging Condensation on lens from coldCondensation on lens from cold
scope on entering warm abdomenscope on entering warm abdomen
Wipe lens on viscera with warmWipe lens on viscera with warm
salinesaline
Cold gasCold gas Use ThermoflatorsUse Thermoflators
Condensation on scope eyepiece,Condensation on scope eyepiece,
camera lenscamera lens
Detach camera from scope andDetach camera from scope and
clean lensclean lens
Flickering,Flickering,
electricalelectrical
interferenceinterference
Moisture in camera cableMoisture in camera cable
connecting plugconnecting plug
Poor cable sheildingPoor cable sheilding
Insecure connection of video cableInsecure connection of video cable
b/n monitorsb/n monitors
Use suction or compressed airUse suction or compressed air
to dry out moistureto dry out moisture
Replace cables as necessaryReplace cables as necessary
and move ESU away fromand move ESU away from
video equipmentvideo equipment
Reattach video cable at eachReattach video cable at each
monitormonitor
Blurring,Blurring,
distortiondistortion
Incorrect focusIncorrect focus
Cracked lens, internal moistureCracked lens, internal moisture
Too grainyToo grainy
Focus the cameraFocus the camera
Inspect scope/camera sosInspect scope/camera sos
replacereplace
Adjust enhancements or grainAdjust enhancements or grain

24. Suction / IrrigationSuction / Irrigation
 Occlusion ofOcclusion of
tubing (kinking,tubing (kinking,
blood clot, etc.)blood clot, etc.)
 Occlusion ofOcclusion of
valves invalves in
suction/irrigatorsuction/irrigator
devicedevice
 Inspect full lengthInspect full length
of tubing. Ifof tubing. If
necessary, detachnecessary, detach
from instrumentfrom instrument
and flush tubingand flush tubing
with sterile salinewith sterile saline
 Detach tubing,Detach tubing,
flush device withflush device with
sterile salinesterile saline

25. Suction / IrrigationSuction / Irrigation
 Not attached to wallNot attached to wall
suction/machinesuction/machine
 Irrigation fluidIrrigation fluid
container notcontainer not
pressurizedpressurized
Inspect and secureInspect and secure
suction & wall sourcesuction & wall source
connectorconnector
Inspect compressedInspect compressed
gas source, connector,gas source, connector,
pressure dial settingpressure dial setting

26. Expertise ProblemsExpertise Problems

27. HAND EYEHAND EYE
COORDINATIONCOORDINATION
 Surgeon must develop good hand eyeSurgeon must develop good hand eye
coordination before attempting anycoordination before attempting any
laparoscopic surgery by constantlaparoscopic surgery by constant
practice on the pelvi Trainer.practice on the pelvi Trainer.

28. Camera HoldingCamera Holding
 Assistant should stand on the Rt sideAssistant should stand on the Rt side
of the Patient and be an expert atof the Patient and be an expert at
holding the camera & must anticipateholding the camera & must anticipate
the next steps of the surgery helpingthe next steps of the surgery helping
the smooth progression.the smooth progression.

29. Operative Techniques-Operative Techniques-
Large Uteri-Large Uteri-
 Position the primary and lateralPosition the primary and lateral
ports higher.ports higher.
 Use your ports efficiently alongUse your ports efficiently along
with a good vaginal manipulatorwith a good vaginal manipulator
with patient’s buttockswith patient’s buttocks
protruding beyond the edge ofprotruding beyond the edge of
the table to give traction counterthe table to give traction counter
traction to make the structurestraction to make the structures
more taut so that cauterizationmore taut so that cauterization
and dissection or cuttingand dissection or cutting
becomes easy.becomes easy.
 Myoma screw is very helpful forMyoma screw is very helpful for
traction.traction.

30. Creation Of PlanesCreation Of Planes
While pushing the UVWhile pushing the UV
fold-fold-
 try coming from the lateral edgestry coming from the lateral edges
towards the centretowards the centre
 If you still don’t happen to get theIf you still don’t happen to get the
plane- convert TLH to LAVHplane- convert TLH to LAVH
In Adhesiolysis –In Adhesiolysis –
 Always start from the normalAlways start from the normal
anatomy and proceed towads theanatomy and proceed towads the
abnormal as the planes open up.abnormal as the planes open up.
 Use harmonic as the cavitationalUse harmonic as the cavitational
effect will help the creation of planes.effect will help the creation of planes.

31. Operative Techniques-Operative Techniques-
 Intra operative bleeding-Intra operative bleeding-
 Always cut less and cauterize moreAlways cut less and cauterize more
 If at all bleeding occurs- first see-don t compriseIf at all bleeding occurs- first see-don t comprise
on vision-by repeated suction irrigation-isolate theon vision-by repeated suction irrigation-isolate the
bleeder and coagulatebleeder and coagulate

32. Tissue RetrievelTissue Retrievel
CLOTS in EctopicCLOTS in Ectopic
pregnancypregnancy
 Spoon forcepsSpoon forceps
 High pressure irrigation and suctionHigh pressure irrigation and suction
 10mm suction cannula10mm suction cannula
 ColpotomyColpotomy
 EndobagEndobag

33. Tissue RetrievelTissue Retrievel
Removal ofRemoval of
degenerated fibroidsdegenerated fibroids
like cystic , calcifiedlike cystic , calcified
fibroids are difficultfibroids are difficult
toto morcellatemorcellate
 colpotomy is acolpotomy is a
better optionbetter option..

34. If the myomaIf the myoma
screw breaksscrew breaks
during theduring the
enucleation of theenucleation of the
fibroid.fibroid.
-- remove the brokenremove the broken
piece as it may damagepiece as it may damage
the morcellator blade ifthe morcellator blade if
it touches the bladeit touches the blade
during morcellationduring morcellation

35. Loss of PneumoperitoneumLoss of Pneumoperitoneum
after Colpotomyafter Colpotomy
 Use uterus as aUse uterus as a
pneumo occluderpneumo occluder
 Ceanna Glove- wetCeanna Glove- wet
sponge in a glovesponge in a glove
as a pneumoas a pneumo
occluder.occluder.
 VariousVarious
manipulators withmanipulators with
inbuilt pneumo-inbuilt pneumo-
occluders.occluders.

36. EndosuturingEndosuturing
 Practice makes onePractice makes one
perfectperfect
 Use short length ofUse short length of
suture materialsuture material

37. Electro Surgical UnitsElectro Surgical Units

38.  Patient notPatient not
groundedgrounded
properlyproperly
 ConnectionConnection
between electro-between electro-
surgical unit andsurgical unit and
instrument looseinstrument loose
 Foot pedal orFoot pedal or
hand switch nothand switch not
connected toconnected to
electrosurgicalelectrosurgical
unitunit
 AssureAssure
adequateadequate
return padreturn pad
contactcontact
 Inspect bothInspect both
connectingconnecting
pointspoints
 MakeMake
connectionconnection

39. ELECTRO-SURGICAL UNITELECTRO-SURGICAL UNIT
 Wrong outputWrong output
selectedselected
 Connected to theConnected to the
wrong socket onwrong socket on
the electrosurgicalthe electrosurgical
unitunit
 InstrumentInstrument
insulation failureinsulation failure
outside of surgeon’soutside of surgeon’s
viewview
 Correct outputCorrect output
choicechoice
 Check that cable isCheck that cable is
attached to properattached to proper
socketsocket
 Use new instrumentUse new instrument
and inspectand inspect
insulationinsulation

40. Electrosurgical UnitElectrosurgical Unit
 CauteryCautery
smokesmoke
obscuresobscures
visionvision
 If Bipolar isIf Bipolar is
not working,not working,
 -do suction and-do suction and
remove theremove the
smoke, instead ofsmoke, instead of
opening the ventopening the vent
of the trocar as itof the trocar as it
will preventwill prevent
inhalationinhalation
for coagulation usefor coagulation use
monopolarmonopolar
thermocoagulationthermocoagulation

41. Electro Surgical UnitElectro Surgical Unit
 Lateral spread-use harmonic when close to vitalLateral spread-use harmonic when close to vital
structures or sharp dissection with scissorsstructures or sharp dissection with scissors
 Use bipolar whenever appropriateUse bipolar whenever appropriate
 Coagulate with cutting current as it is lowCoagulate with cutting current as it is low
voltagevoltage

42. Antagonism FromAntagonism From
Fellow GynaecologistsFellow Gynaecologists

43.  N2O causes bowel distention- switchN2O causes bowel distention- switch
to mixture of O2 and Airto mixture of O2 and Air
 Switch over to sevoflurane for smoothSwitch over to sevoflurane for smooth
recoveryrecovery
Problems Caused byProblems Caused by
AnaesthetiaAnaesthetia

44. Financial ProblemsFinancial Problems
 Costly equipmentsCostly equipments
 TackersTackers
 MeshMesh

45. CONCLUSIONCONCLUSION
 Patience and persistence can help you master thePatience and persistence can help you master the
laparoscopic surgical technique. Efficiencylaparoscopic surgical technique. Efficiency
increases with experience and remember it is aincreases with experience and remember it is a
team effort and first build a good ground supportteam effort and first build a good ground support
team and train them well.team and train them well.

46.  THANK U FOR A PATIENT HEARINGTHANK U FOR A PATIENT HEARING