Laparoscopy

Question 1

Laparoscopy risks

Answer 1

o Death 1:15,000
o Bowel injury 2:1000
o Vascular injury 1:1000
o Urological injury 0.5:1000
o Hernia at port site 1:100
o Bleeding, transfusion
o Infection
o Shoulder tip pain
o Conversion to open
o Adhesion formation
o Failure to achieve symptom improvement
o General risks
- Anaesthetic
- DVT/PE
- Pneumonia/atelectasis

Question 2

Procedure of laparoscopy

Answer 2

• Preparation
  Appropriate informed consent
  General anaesthesia
  o bhCG
  o Empty bladder, instrument uterus
  o Position
• Horizontal table
• Buttocks at edge of bed (but not off)
• Hips flexed and abducted, knees flexed (low lithotomy)
  o Palpate aorta and sacral promontory
• Entry technique
  o Hasson – open technique
  o Veress – closed technique
• Check Veress prior
  -Incision into skin
• Insert veres needle perpendicular to sheath, then aim for centre of pelvis
• Test with aspiration, saline drop test, low insufflation pressure <8mmHg
• Intra-abdominal pressure 15-25mmHg prior to placement of primary-trochar to maximise distance from sheath to bowel
• Then reduce pressure to 15mmHg
  o Direct optical entry – closed technique
  o Palmer’s point
• Indications
• Known umbilical adhesions
• History of umbilical hernia
• Failed insufflation at umbilicus
• Very thin patient
• Deflate stomach
• Palpate for hepatospenomegaly
• Place Veress 3cm below left costal margin in midclavicular line
• Following port placement, put camera in lateral port to inspect trochar entry point

Question 3

Comparison of entry points

Answer 3

• Comparison of entry techniques
  o Bowel injury Veress<direct<open
  o Vascular injury direct<open<Veress
  o Cochrane concluded no evidence of advantage of any technique in preventing major vascular or visceral injuries
  o Open entry had fewer failed entry rates compared to Veress
  o Direct entry had fewer failed entry, less extraperitoneal insufflation and less
  omental injury compared to Veress
• Increased recognition of injury with direct visual entry