Laparoscopic Surgery
Barkett:
- For trocar incisions: Hold scalpel flat/parallel to body, push into inferior umbilicus and push through and up away from body to make incision. Do not hold knife up and down. After insertion of veress, move veress to see if it feels like you are into peritoneum.
- Single-tooth tenaculum placed vertically across anterior cervix.
Gale-Butto:
- For trocar incisions: Place allis clamps on each side of umbilicus, pull up and make incision through base of umbilicus. Then place towel clamps on each side of umbilicus, pull straight up, and push veress needle straight down, then hold in place while pneuomoperitoneum is obtained.
- When placing trocars, use constant downward pressure until through the fascia, never back off and reapply pressure.
- Never use the uterine sound. Always dilate outer os of the cervix (only put the dilator in 2cm), but not the inner os. Then, if using hysteroscope, apply constant pressure to back end of scope holding in the same hand as the single tooth tenaculum to push through into the cavity.
- Always scan up to liver/gallbladder first, then when the patient is being put in trendelenberg, visualize the appendix as it goes over the pelvic brim...then complete scan of pelvis.
- If creating larger incision or using 10mm trocar... always place midline - either suprapubic or umbilical.
- Consider placing camera in one of the lateral ports to have assistant control, and then surgeon on operate through umbilical and ipsilateral incisions.
Cree:
- For trocar incisions: "Bury the blade" to make the incision, then uses sharp trocars.
- Places first tocar blind, no veress first.
- Always sound before dilating cervix for uterine sound placement
- Closure: with dermabond only (now sometimes uses suture to close)
Sikkenga:
- Always scan up to liver/gallbladder and appendix first, then complete scan of pelvis.
- Always has expanding trocar on card for every laparoscopy, only definitely uses it for hysterectomy to allow introduction of Endostitch.
- Endostitch (with Quill suture in running closure of cuff): Use grasper to pull cranially on posterior cuff, then use hold endostitch open across cuff near grasper, with needle in posterior jaw, then slide laterally to place first stitch at corner, as close to uterosacral ligament as possible. Squeeze to close endostitch jaws, making sure you go through vaginal mucosa. Then, toggle switch 3 times to pass needle to the anterior jaw. Open jaws completely and pull anteriorly and cranially to pull needle through tissue. Once needle is through, close jaws before you pull cranially to pull suture through tissue, leaving a tail with the loop on the end. In the same fashion, pass needle through anterior cuff, and pull suture through. Then pass the needle through the loop at the end of the suture and pull tight. Continue in running fashion across cuff. Once you have reach the opposite side, you have to come back at least one throw to secure suture. Cut suture with no tail to avoid quills causing injury. *Always toggle the needle 3 times every time you pass it through tissue, and use anterior, then cranial force to pull needle through tissue. http://www.medtronic.com/covidien/products/hand-instruments-ligation/endoscopic-suturing-devices
Tryksa:
- No veress needle, place initial trocar with direct visualization.
- Always scan up to liver/gallbladder first, then when the patient is being put in trendelenberg, visualize the appendix as it goes over the pelvic brim...then complete scan of pelvis.
- Never use the uterine sound.
Lawrence:
- Vertical incision (10mm) in umbilical fold, veress to achieve pneumo, then 10mm port for camera. Add 5mm suprapubic trocar for diagnostic laparoscopy.
- Close fascia of 10mm port by grasping the fascia just below the umbiilicus with an alice clamp, then closure with 0 vicryl.
Brader:
Removal of large masses during laparoscopy:
- After the ovary mass is removed from pedicle (or supracervical hyst, or fibroid)
- Remove one of the midline trocars. And extend skin incision as needed with scalpel.
- Place kocher clamp through fascia and extend fascial incision (use mayo scissors if needed)
- Place 15mm VATS bag (stronger than endocatch bags) through incision without trocar and place mass in bag.
- Pull bag up through incision and use scissors and kochers to morcellate in bag.
- Close fascia with multiple carter-thomason stitches.
Cystectomy:
- Use microline scissors (usually without cautery) to cut through first layer of tissue, then use 2 Maryland graspers to pull edges apart and peel away from cyst. Once, cyst is removed, remove in endocatch.
- Cautery or floseal to control bleeding on ovary, then wrap ovary with intercede and no suturing necessary.
Davinci Trocar placement:
- Veress at palmers point for all Davinci's.
- Camera is 25cm from pubic symphysis. Arm 1 and 2 trocars are 10cm lateral and 3cm inferior to camera port.
- 3rd arm is on pts left, approx. 8-10cm lateral to arm 2.
- Assist port is in upper left, triangulated above and between camera and arm 2.
Traditional laparoscopy:
- 5mm sharp trocar in umbilicus for most (camera is place higher for large masses).
- Additional trocars placed on left, approx. 10cm from umbilicus, and suprapubic.
(This port placement allows surgeon, on left, to control instruments, while assistant controls camera)
Incision closure:
- 4-0 monocryl for skin incisions >8mm or with a lot of tension.
- Close all other incisions with liquiband: Hold each end of incision with adson's to pull incision closed. Apply liquiband to incision and pinch incision to evert edges and hold incision closed. Liquiband is able directly over incision and approx. 3-5mm around incision edges to create "scab".