1. James
Bentley

2. ¡ Safety
for
the
patient
¡ Comfort
for
the
surgeon
and
assistants
¡ Access
to
perform
surgery

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. ¡ 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. ¡ Primary
Trocar
¡ Accessory
Trocars

6. ¡ Veres
Needle
¡ Direct
Trocar
Insertion
¡ Open
Laparoscopy
with
Hasson

7. Open
Laparoscopy
With
Hasson
Trocar

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. ¡ 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. ¡ 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. ¡ 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. Direct Trocar Insertion

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. ¡ Advantages
§ reduces
number
of
blind procedures
§ decreased
operating
time
¡ Disadvantages
§ similar
risks
of
viscus
and
vascular
injuries

15. ¡ Veres
Needle
¡ Direct
Trocar
Insertion
¡ Open
Laparoscopy
with
Hasson

16. Preperitoneal Insufflation: Management?

17. ¡ The
closer
your
skin
incision
is
to
the
center
of
the
umbilicus,
the
lesser
the
chance

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. ¡ Always
insert
these
under
direct
vision
¡ Try
to
avoid
the
inferior
epigastric
artery
and
vein

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. ¡ Surgeon’s
responsibility
to
perform
operative
laparoscopy
safely
and
effectively
¡ Requires
greater
time
and
attention
to
details
such
as
positioning,
access,
and
equipment