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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 168 - LAPAROSCOPY

Page 1 of 1 [1]
		Posted by Shakira B. Tue Aug 16, 2005 05:43 pm
A) Laparoscopic complications can be due to the scope itself or the procedure. Overall complications are 5.7/1000. Due to the diagnostic procedures the complications are 1/1000 and with advanced procedures 8-18/1000. Pre-operative:- Adequate training in operative techniques including directing instruments appropriately helps to reduce the rate of injuries. Recognizing high risk cases like obese person, previous abdominal surgery, previous intra-abdominal sepsis, crohns disease and use alternative procedure. Training and diathermy and laser is required. Intra-operative:- Open laparoscopy reduces the risk to normally situated bowel by Hasson technique. Safe entry of verrus needle into the abdominal cavity at 45 degree angle inserted via the umbilicus. Intra-abdominal pressure should be 15-18 mmhg. The patient should lie supine on the table. Most dangerous time of visceral injury are during insertion of verrus needle and primary trochar. Using an alternative site of entry, the initial trochar may be placed away from the site of previous incision in an attempt to avoid fixed bowel. Insertion of a micro-laparoscope in the left upper quadrant with the subsequent insertion of umbilical trochar under direct vision reduces the risk in adherent bowel. After insertion verrus needle should be checked for correct intra-peritoneal position by palmers test and noting pressure at entry. 10-20 ml saline pushed through syringe and then in the abdominal cavity, when withdrawn nothing comes out means correct entry. Creation of high pressure pneumoperitoneum reduces initial trochar injury. This high pressure setting is then lowered as soon as safe abdominal entry is confirmed. The use of guarded point instrument and the introduction of second and subsequent ports under direct vision may reduce the risk further in all patients. Post-operative:- Bowel injury should be considered in the presence of excessive pain, shoulder tip pain, tachycardia, and pyrexia. High index of suspicion and early opinion from a surgeon is essential to avoid further complication and mortality. b) The recognition of injury at the time of operation may be assisted by noting the contents of bowel on the tip of instruments. It may go un noticed if the injured area is empty or not in the field of vision. Minor injury to the bowel may be repaired laproscopically by a surgeon or a gynecologist experienced in laparoscopic suturing. Second opinion from surgeon is helpful in uncertain cases. In most cases it is safer to perform a laparotomy with a midline vertical incision. To allow careful inspection of the whole bowel and open repair of any damage. Patient should be covered with broad spectrum antibiotics. After the surgery patient should be explained about the findings and incident form filled up.
		Posted by Rani M. Tue Aug 16, 2005 06:44 pm
Visceral injuries may occur in 0.4-3/1000 laproscopic procedures leading to unintended laprotomy, additional surgical procedures and increased perioperative morbidity. These are one of the common causes of litigation. High risk factors for visceral injuries are previous abdominal/ pelvic surgries, endometriosis, previous pelvic abscess or PID and obese women. Therefore, proper selection of patients and ensuring that laproscopy is the right choice as compared to other alternatives i.e medical management or open laprotomy is essential. High risk cases and where difficulties are anticipated should be performed by the senior most gynecologist. Proper training and adequate experience are essential in minimising complications. Correct maintenance of equipments & laproscope ensure optimum visualisation and thus minimise risk of injuries. Bladder should be emptied prior to procedure to avoid injury to bladder and continuous drainage is required if procedure is expected to last more than 30 minutes. Most injuries occur during entry as it is a blind technique. Open entry (Hasson Technique ) has been advocated by general surgeons . It may minimise risk of vascular injuries but there is no evidence that it reduces risk of injury to adherent bowel. Veress needle should be checked for spring loaded mechanism to prevent sharp injuries and checked for patency before insertion.After insertion saline test is advocated to confirm intraperitoneal entry.This involves first aspirating by a syringe to see if blood or faeculant matter is aspirated , then injecting some saline and withdrawing again. If correct position of needle , nothing will be aspirated. Needle should not be moved inside the abdomen as it increases risk of injury and increase size of hole if already ocurred. Gas flow should be high flow and low pressure. 10 mm Hg or less indicate correct intraperitoneal entry.High pressure may be due blockage of needle or entry into a viscera. Alternative sites of entry may be used if adhesions are suspected such as suprapubic or posterior vaginal fornix. Palmers point( left hypochondrium in mid clavicular line just below the 9 th intercostal space) may be used to insert micro laproscope and subsequent insertion of umblical trocar under vision. Splenomegaly should be ruled out prior to it. Most injuries occur due to trocars. Shortest possible trocar for that patient and guarded point trocars should be used.Trocars should be inserted when about 25 mm Hg intraabdominal pressure is maintained. Routine use of 3 litre of gas may not be correct for all patients .Secondary trocars should be inserted under direct vision. After insertion of all trocars intraabdominal pressure is again reduced to 15 mm Hg. Correct operative technique and performing all procedures under direct vision are essential .After laproscope entry a 360 degree view of all structures should be done.Recourse to laprotomy if difficulties are anticipated should not be taken as loss of face.Removal of secondary trocars should be under vision and while removing primary trocar care should be taken not to pull a bowel loop .Large defects should be closed properly. Post op, close monitoring is required for early detection and management of complications. (b) Involvement and assistance of senior gynocologist, general surgeons or urologist should be taken if bowel or urinary tract injuries are identified during laproscopy. If injury is due to veress needle & is only to serosa of bowel or is small it may be repaired laproscoically by an experienced operator But is is safer to resort to laprotomy in most of the injuries. Laproscope and trocar should be left in place to minimise spilling of bowel contents and to guide the operator to perforation. Incision is extended along the umblical incision. Thorough and complete examination of large and small bowel should be done. Injuries may involve multiple bowel loops. Repair is done as appropiate to injury.Small injuries may be sutured, larger may require resection and anastomosis and rarely colostomy may be needed. Close post op care is essential preferably in ICU for 24 hours. Pulse, temperature, B.P and urine output should be monitored. Broad spectrum antibiotics should be given as fecal peritonitis carry high mortality and to avoid septicemia. Risk management form should be filled and complication and procedure done should be discussed with the patient and her family as soon as possible.
		Posted by Mangala sundari R. Wed Aug 17, 2005 12:21 pm
Laparoscopy is associated with visceral. vascular or ureteric injury during the entry or exit or during surgery. It can be mechanical or electrosurgical injury. The incidence is 1 in 2500 for visceral and 1 in 5000 for vascular injury. Visceral injury is of 2 types. Type 1 is injury by needle or trocar during the entry to a normally situated bowel and type 11 is injury to the adherent bowel to the abdominal wall. The injury can be to omentum, bowel, bladder , ureter, or to pelvic organs. Pre operative assessment is of utmost important to assess the at risk patients.Any previous abdominal or pelvic surgery,umbilical hernia repair,the type of incisions pfannensteil, midline, or transverse incisions are noted. H/o PID, endometriosis, fibroids ,malignancy, or second look laparoscopy increase the presence ofadhesions . Pre operative bowel preparation and nil orally for for 6 to 8 hours advised and counselling regarding the procedure and complications and informed consent taken.should go through her file for any details and prophylactic antibiotics should be given. Positioning of the patients should be horizontal during entry to avoid major vessels and should take iliac crest as the marking point rather than the umbilicus ( may be variable) which will correspond to L4 for aortic bifurcation. Emptying the bladder , re assess the pelvic findings and the mobility of the structures before the start of the procedure. Check the integrity of the veress needle , gas flow , and the spring action before inserting.The spring action prevents the sharp entry to the bowel. The anterior abdominal wall should be lifted up so as the bowels fall away from the abdominal wall. Select a point just below the umbilicus which is the thinnest and avascular point in the abdominal wall . The needle should not be thrust furthur once it is inside the peritoneal cavity. Check the position by saline test which will be sucked in due to negative pressure. Intraabdominal pressure should be around 20 to 25 mm during insertion and to reduce to 10 to 12 mm during the surgery. This will maintain the blood flow to the vital organs and less anesthesia complications in the trendelenberg position. Needle should not be swung inside the abdomen once it is inside. There may be difficulties in a very thin and very obese individuals. Select the appropriate sized needles. Adequate pneumoperitoneum and trendelenberg position will displace the bowel away from the pelvis. If the entry cannot be accessed through this sub umbilical area then we can select the Palmers point which is 3 cms below the costal margin in the midclavicular line on the left , but should rule out spleenomegaly. There are mini laparoscopes <2 mm which can be used to study the periumblical adhesions palmers point . If any doubt of adhesions, open laparoscopy can be done through the subumblical incision, and the scope introduced under vision and secured. Optically illuminated laparocopes can guide the entry through the abdominal wall layers. After the introduction of the trocar while removing the plunger, look for any bleeding or bowel contents.If indoubt, should not withdraw the trocar and leave it in its place. Either go through the palmers point and verify the injury or take the surgeons help for laparotomy. After introduction of the laparocope, go thro 360 degree in the abdomen to look for any bowel or vascular injury. Seconday ports usually in the lower abdomen either in the midline or lateral ports should be under vision under illumination to avoid epigastric vessles, and the adhesions. During the surgery, the injury can be mechanical or electrosurgical.only one third of injuries are noticed during the procedure and 70% go unnoticed and present as late as 30 days later with peritonitis. Careful division of the adhesions and using bipolar cautery instead of unipolar with adequate insulation and using stapler clips instead of cauterizing especially near the ureter during lymph node dissection will avoid thermal injury. Saline irrigation should be used liberally during cautery. Electrical connections should be verified to avoid any short circuit or failure . During exit, the the trocars and the sheaths should be removed under vision, and the scope should be in the trocar till complete removal.Rapid removal or empty trocar may suck a loop of bowel into the lumen of the instrument. Principles: If the veress needle has been inseted with no tearing then conservative management, bowel rest,antibiotics and observation appear to be appropriate. If the the trocar has penetrated the bowel, it is best to leave it in place, to mark the injury.some injuries can be repaired laparoscopically and others may need laparotomy.Adequate training, instruments and expertise is necessary to deal with such complications. Omental injuries are usually hemorrhagic can be secured with cautery or ligatures . Bladder injury is more readily visible than bowel injury and treated .Laparoscopy is associated with visceral. vascular or ureteric injury during the entry or exit or during surgery. It can be mechanical or electrosurgical injury. The incidence is 1 in 2500 for visceral and 1 in 5000 for vascular injury. Visceral injury is of 2 types. Type 1 is injury by needle or trocar during the entry to a normally situated bowel and type 11 is injury to the adherent bowel to the abdominal wall. The injury can be to omentum, bowel, bladder , ureter, or to pelvic organs. Pre operative assessment is of utmost important to assess the at risk patients.Any previous abdominal or pelvic surgery,umbilical hernia repair,the type of incisions pfannensteil, midline, or transverse incisions are noted. H/o PID, endometriosis, fibroids ,malignancy, or second look laparoscopy increase the presence ofadhesions . Pre operative bowel preparation and nil orally for for 6 to 8 hours advised and counselling regarding the procedure and complications and informed consent taken.should go through her file for any details. Positioning of the patients should be horizontal during entry to avoid major vessels and should take iliac crest as the marking point rather than the umbilicus ( may be variable) which will correspond to L4 for aortic bifurcation. Emptying the bladder , re assess the pelvic findings and the mobility of the structures before the start of the procedure. Check the integrity of the veress needle , gas flow , and the spring action before inserting.The spring action prevents the sharp entry to the bowel. The anterior abdominal wall should be lifted up so as the bowels fall away from the abdominal wall. Select a point just below the umbilicus which is the thinnest and avascular point in the abdominal wall . The needle should not be thrust furthur once it is inside the peritoneal cavity. Check the position by saline test which will be sucked in due to negative pressure. Intra abdominal pressure should be around 20 to 25 mm during insertion and to reduce to 10 to 12 mm during the surgery. This will maintain the blood flow to the vital organs and less anesthesia complications in the trendelenberg position. Needle should not be swung inside the abdomen once it is inside. There may be difficulties in a very thin and very obese individuals. Select the appropriate sized needles. Adequate pneumoperitoneum and trendelenberg position will displace the bowel away from the pelvis. If the entry cannot be accessed through this sub umbilical area then we can select the Palmers point which is 3 cms below the costal margin in the midclavicular line on the left , but should rule out spleenomegaly. There are mini laparoscopes <2 mm which can be to study the proumblical adhesions thro the Patient should be explained about the nature of injury after the procedure. Palmers point . If any doubt of adhesions, open laparoscopy can be done through the subumblical incision, and the scope introduced and secured. Optically illuminated laparocopes can guide the entry through the abdominal wall layers. After the introduction of the trocar while removing the plunger, look for any bleeding or bowel contents.If indoubt, should not withdraw the trocar and leave it in its place. Either go through the palmers point and verify the injury or take the surgeons help for laparotomy. After introduction of the laparocope, go thro 360 degree in the abdomen to look for any bowel or vascular injury. Seconday ports usually in the lower abdomen either in the midline or lateral ports should be under vision under illumination to avoid vessles, and the adhesions. During the surgery, the injury can be mechanical or electrosurgical.only one third of injuries are noticed during the procedure and 70% go unnoticed and present as late as 30 days later with peritonitis. Careful division of the adhesions and using bipolar cautery instead of unipolar with adequate insulation and using stapler clips instead of cauterizing especially near the ureter during lymph node dissection will avoid thermal injury. Saline irrigation should be used liberally during cautery. Electrical connections should be verified to avoid any short circuit or failure . During exit, the the trocars and the sheaths should be removed under vision, and the scope should be in the trocar till complete removal.Rapid remaval or empty trocar may suck a loop of bowel into the lumen of the instrument. Principles: If the veress needle has been inseted with no tearing then conservative management, bowel rest,antibiotics and observation appear to be appropriate. If the the trocar has penetrated the bowel, it is best to leave it in place, to mark the injury.some injuries can be repaired laparoscopically and others may need laparotomy.Adequate training, instruments and expertise is necessary to deal with such complications. Omental injuries are usually hemorrhagic can be secured with cautery or ligatures . Bladder injury is more readily visible than bowel injury and treated laparoscopically or by laparotomy and managed by continuous drainage and antibiotics. Laparoscopy is associated with visceral. vascular or ureteric injury during the entry or exit or during surgery. It can be mechanical or electrosurgical injury. The incidence is 1 in 2500 for visceral and 1 in 5000 for vascular injury. Visceral injury is of 2 types. Type 1 is injury by needle or trocar during the entry to a normally situated bowel and type 11 is injury to the adherent bowel to the abdominal wall. The injury can be to omentum, bowel, bladder , ureter, or to pelvic organs. Pre operative assessment is of utmost important to assess the at risk patients.Any previous abdominal or pelvic surgery,umbilical hernia repair,the type of incisions pfannensteil, midline, or transverse incisions are noted. H/o PID, endometriosis, fibroids ,malignancy, or second look laparoscopy increase the presence ofadhesions . Pre operative bowel preparation and nil orally for for 6 to 8 hours advised and counselling regarding the procedure and complications and informed consent taken.should go through her file for any details. Positioning of the patients should be horizontal during entry to avoid major vessels and should take iliac crest as the marking point rather than the umbilicus ( may be variable) which will correspond to L4 for aortic bifurcation. Emptying the bladder , re assess the pelvic findings and the mobility of the structures before the start of the procedure. Check the integrity of the veress needle , gas flow , and the spring action before inserting.The spring action prevents the sharp entry to the bowel. The anterior abdominal wall should be lifted up so as the bowels fall away from the abdominal wall. Select a point just below the umbilicus which is the thinnest and avascular point in the abdominal wall . The needle should not be thrust furthur once it is inside the peritoneal cavity. Check the position by saline test which will be sucked in due to negative pressure. Intra abdominal pressure should be around 20 to 25 mm during insertion and to reduce to 10 to 12 mm during the surgery. This will maintain the blood flow to the vital organs and less anesthesia complications in the trendelenberg position. Needle should not be swung inside the abdomen once it is inside. There may be difficulties in a very thin and very obese individuals. Select the appropriate sized needles. Adequate pneumoperitoneum and trendelenberg position will displace the bowel away from the pelvis. If the entry cannot be accessed through this sub umbilical area then we can select the Palmers point which is 3 cms below the costal margin in the midclavicular line on the left , but should rule out spleenomegaly. There are mini laparoscopes <2 mm which can be to study the proumblical adhesions thro the Patient should be explained about the nature of injury after the procedure. Palmers point . If any doubt of adhesions, open laparoscopy can be done through the subumblical incision, and the scope introduced and secured. Optically illuminated laparocopes can guide the entry through the abdominal wall layers. After the introduction of the trocar while removing the plunger, look for any bleeding or bowel contents.If indoubt, should not withdraw the trocar and leave it in its place. Either go through the palmers point and verify the injury or take the surgeons help for laparotomy. After introduction of the laparocope, go thro 360 degree in the abdomen to look for any bowel or vascular injury. Seconday ports usually in the lower abdomen either in the midline or lateral ports should be under vision under illumination to avoid vessles, and the adhesions. During the surgery, the injury can be mechanical or electrosurgical.only one third of injuries are noticed during the procedure and 70% go unnoticed and present as late as 30 days later with peritonitis. Careful division of the adhesions and using bipolar cautery instead of unipolar with adequate insulation and using stapler clips instead of cauterizing especially near the ureter during lymph node dissection will avoid thermal injury. Saline irrigation should be used liberally during cautery. Electrical connections should be verified to avoid any short circuit or failure . During exit, the the trocars and the sheaths should be removed under vision, and the scope should be in the trocar till complete removal.Rapid remaval or empty trocar may suck a loop of bowel into the lumen of the instrument. Principles: If the veress needle has been inseted with no tearing then conservative management, bowel rest,antibiotics and observation appear to be appropriate. If the the trocar has penetrated the bowel, it is best to leave it in place, to mark the injury.some injuries can be repaired laparoscopically and others may need laparotomy.Adequate training, instruments and expertise is necessary to deal with such complications. Omental injuries are usually hemorrhagic can be secured with cautery or ligatures . Bladder injury is more readily visible than bowel injury and treated laparoscopically or by laparotomy and managed by continuous drainage and antibiotics. . uterine perforation or shearing injuries of tubes are maneged laparoscopically or by laparotomy and hemostatsis abtained. If any difficulty is encountered during the laparoscopy, should not hesitate to convert to laprotomy and take necessary help from surgeons, or urologists or senior colleagues. Closure of incisions if more than 10 mm port should involve the closure of the sheath to avoid hernia. Trauma to small bowel will present earlier than the large bowel and thermal injuries may present later than 36 hrs or up to 30 days due to tissue necrosis. Persistent pain , abdominl distension, fever, and absent bowel sounds following laparoscopic surgery should alert us for visceral injury. Post op pyrexia is unusual in lap surgery. Risk management form should be filled and patient should be explained about the nature of injury after the procedure. .
		Posted by Mangala sundari R. Wed Aug 17, 2005 12:36 pm
Dr.Paul, I think there was some mishap while sending the text.Please bear with me and ignore the previous one which is all jumbled up. Laparoscopy is associated with visceral. vascular or ureteric injury during the entry or exit or during surgery. It can be mechanical or electrosurgical injury. The incidence is 1 in 2500 for visceral and 1 in 5000 for vascular injury. 0.6 %happens during the diagnostic and 1.3 % of injuries happen during the operative procedures. Visceral injury is of 2 types. Type 1 is injury by needle or trocar during the entry to a normally situated bowel and type 11 is injury to the adherent bowel to the abdominal wall. The injury can be to omentum, bowel, bladder , ureter, or to pelvic organs. Pre operative assessment is of utmost important to assess the at risk patients.Any previous abdominal or pelvic surgery,umbilical hernia repair,the type of incisions pfannensteil, midline, or transverse incisions are noted. H/o PID, endometriosis, fibroids ,malignancy, or second look laparoscopy increase the presence ofadhesions . Pre operative bowel preparation and nil orally for for 6 to 8 hours advised and counselling regarding the procedure and complications and informed consent taken.should go through her file for any details. Positioning of the patients should be horizontal ( or may be 15degree tilt) during entry to avoid major vessels and should take iliac crest as the marking point rather than the umbilicus ( may be variable) which will correspond to L4 for aortic bifurcation. Emptying the bladder , re assess the pelvic findings and the mobility of the structures before the start of the procedure. Check the integrity of the veress needle , gas flow , and the spring action before inserting.The spring action prevents the sharp entry to the bowel. The anterior abdominal wall should be lifted up so as the bowels fall away from the abdominal wall. Select a point just below the umbilicus which is the thinnest and avascular point in the abdominal wall . The needle should not be thrust furthur once it is inside the peritoneal cavity. Check the position by saline test which will be sucked in due to negative pressure. Intra abdominal pressure should be around 20 to 25 mm during insertion and to reduce to 10 to 12 mm during the surgery. This will maintain the blood flow to the vital organs and less anesthesia complications in the trendelenberg position. Needle should not be swung inside the abdomen once it is inside. There may be difficulties in a very thin and very obese individuals. Select the appropriate sized needles. Adequate pneumoperitoneum and trendelenberg position will displace the bowel away from the pelvis. If the entry cannot be accessed through this sub umbilical area then we can select the Palmers point which is 3 cms below the costal margin in the midclavicular line on the left , but should rule out spleenomegaly. There are mini laparoscopes <2 mm which can be to study the proumblical adhesions thro the Patient should be explained about the nature of injury after the procedure. Palmers point . If any doubt of adhesions, open laparoscopy can be done through the subumblical incision, and the scope introduced and secured. Optically illuminated laparocopes can guide the entry through the abdominal wall layers. After the introduction of the trocar while removing the plunger, look for any bleeding or bowel contents.If indoubt, should not withdraw the trocar and leave it in its place. Either go through the palmers point and verify the injury or take the surgeons help for laparotomy. After introduction of the laparocope, go thro 360 degree in the abdomen to look for any bowel or vascular injury. Seconday ports usually in the lower abdomen either in the midline or lateral ports should be under vision under illumination to avoid vessles, and the adhesions. During the surgery, the injury can be mechanical or electrosurgical.only one third of injuries are noticed during the procedure and 70% go unnoticed and present as late as 30 days later with peritonitis. Careful division of the adhesions and using bipolar cautery instead of unipolar with adequate insulation and using stapler clips instead of cauterizing especially near the ureter during lymph node dissection will avoid thermal injury. Saline irrigation should be used liberally during cautery. Electrical connections should be verified to avoid any short circuit or failure . During exit, the the trocars and the sheaths should be removed under vision, and the scope should be in the trocar till complete removal.Rapid remaval or empty trocar may suck a loop of bowel into the lumen of the instrument. Principles: If the veress needle has been inseted with no tearing then conservative management, bowel rest,antibiotics and observation appear to be appropriate. If the the trocar has penetrated the bowel, it is best to leave it in place, to mark the injury.some injuries can be repaired laparoscopically and others may need laparotomy.Adequate training, instruments and expertise is necessary to deal with such complications. Omental injuries are usually hemorrhagic can be secured with cautery or ligatures . Bladder injury is more readily visible than bowel injury and treated laparoscopically or by laparotomy and managed by continuous drainage and antibiotics. . If any difficulty is encountered during the laparoscopy, should not hesitate to convert to laaprotomy and take necessary help from surgeons, or urologists. Trauma to small bowel will present earlier than the large bowel and thermal injuries may present later than 36 hrs or up to 30 days due to tissue necrosis. Persistent pain , abdominl distension, fever, and absent bowel sounds following laparoscopic surgery should alert us for visceral injury. Post op pyrexia is unusual in lap surgery. Risk management form should be filled and patient should be explained about the nature of injury after the procedure.
		Posted by Nitin P. Wed Aug 17, 2005 07:29 pm
Laparoscopy is associated with a risk of visceral injury in 6/10,000 cases. Visceral injury leads to infection, peritonitis, prolonged hospital stay, increased morbidity. There is also increased cost to the NHS in the form of litigation and repeat surgery. Preoperative identification of high risk cases such as previous abdominal surgery, documented adhesions, obesity, inflammatory bowel disease is of value. Once a high risk case is identified she must be explained of the higher risk of bowel injury in her case. Consultant presence at such cases also helps in minimising the risk. Training and revalidation of medical staff including theatre staff helps to reduce the risk of visceral injury. Adequate theatre time allocation, so that operative cases are not rushed through is also a useful measure. Training regards the direction of insertion of trocars and use of guarded tip trocars is also important. The equipment for laparoscopy should be checked from time to time and staff should be familiar with the use of the equipment in that centre. Appropriate anaesthesia at the time of laparoscopy helps to reduce risk. Preoperative bowel preparation especially in cases of operative laparoscopy helps with bowel handling at time of surgery. In all cases, it is advisable to insert the Verre?s needle intraumbilically, as this is the thinnest portion of the abdominal wall with fusion of the layers of the abdominal wall. This makes it more likely that it will be inserted intraperitoneal in the first instance avoiding repeated insertions. The position of the Verre?s should be checked with the Palmer?s test and with the pressure gauge on the insuffulator showing low pressure and high flow rate. It is advisable to insert the trocar after getting the intra abdominal pressure to 20-25 mmHg rather than after a fixed volume is insuffulated. At the given pressure there is maximum distance between the abdominal wall and the posterior wall, making insertion safer. Open laparoscopy by Hasson?s technique, direct entry under endotip vision and entry through Palmer?s point are used in cases of adhesions. The Hasson?s technique requires training and increases duration of surgery in the beginning, but is the best method to avoid visceral injury. Second ports must always be inserted under vision, this reduces the risk of visceral injury. Diathermy is used carefully and after appropriate training as it can cause significant visceral injury. Abandoning a procedure due to inappropriate preparation or inadequate training or help should not be seen as face losing. Surgical help should be taken at earliest. b) After identification of a visceral injury, reduction of risk to the patient and the trust are the basic principles of management. Early identification is the key. Appropriate surgical help should be summoned. The consultant and anaesthetist informed of the problem. In most cases, a laparotomy is needed to repair the damage. The further treatment may involve suturing, resection and anastomosis or colostomy depending upon the damage sustained. The patient is transferred to the HDU as she is susceptible to peritonitis and chest infections in the post op periods. The patient and her relatives are explained what went wrong, and what measures were taken to correct the mishap. The risks of any further surgery and anticipated postop complications is also explained. The discussion is documented. An incidental risk form is completed and the risk management team is informed. The patient is explained the procedure regards lodging a complaint if she so wishes.
		Posted by manjula C. Thu Aug 18, 2005 02:41 am
Visceral injury during laparoscopy is a major complication with a an incidence of 1:500, more common during operative than diagnostic laparoscopy. Visceral injuries can occur during entry of Veresse needle, trocars and cannulae, by thermal damage to the bowel from mechanical instruments and during exit of trocars and laparoscope. Injuries can be type I (where normally situated bowel is injured) and type II (damage to the bowel adhered to the abdominal wall). Competent surgeon with surgical expertise and appropriate training in laparoscopic procedures and use of lasers and diathermy is crucial to reduce complications at laparoscopy. Knowledge about the risk factors for bowel adhesions like previous abdominopelvic sepsis, surgery , inflammatory bowel disease and adopting alternative procedures for high risk patients can avoid the bowel injury. Injuries due to entry of Veresse needle can be prevented by high pressure pneumoperitonisation, marking sure that spring loaded mechanism is functioning, following correct technique and direction of needle insertion, stopping at the double snap as soon as the needle enters the peritoneal cavity prevents inadvertent injury to the viscera. Saline hanging drop, saline aspiration and saline mapping tests are meant to ensure the intraperitoneal position of the Veresse needle may not be foolproof. Veresse needle should not be swung under the peritoneum. Open laparoscopy by Hasson’s method can reduce type I bowel injuries and vascular injuries but not type II injuries. Insertion of trocars through alternate entry points may be used in case of suspected adhesions. Entry at palmers’ point, enables visualization of adhesions in the subumbilical area but splenic injury is a possible risk in this approach. Use of point guarded instruments & optical trocars can also help to prevent type I injuries to some extent. Once laparoscope is introduced, a 360o survey of the abdominal cavity should be performed to exclude bowel trauma. Secondary trocars should be introduced under direct vision. Early recourse to laparatomy in difficult cases can prevent bowel injuries to a large extent. Bowel injuries due to thermal damage can be reduced by taking appropriate precautions for rectifying insulation, capacitance failures and accidents. Mechanical injuries can be reduced by proper handling and directing of the instruments during surgery. Injuries to bowel at exit are prevented by removing all ports under vision, during removal of umbilical port laparoscope should protrude from the port during its removal. Injuries identified at laparoscopy are managed in consultation with bowel surgeon. Proper assessment of the extent of damage and appropriate repair is vital. Minor injuries may be repaired laparoscopically by a trained operator. Laparatomy is needed for severe injuries. If Veresse needle has been inserted into the bowel with no tearing, then conservative management with antibiotics and observation is appropriate.. If trocar has penetrated the bowel, it is left in situ to mark the site of injury, laparatomy done and bowel sutured in two layers in such a way as to avoid stricture formation. There should be copious peritoneal irrigation. Thermal injuries may require excision of the devitalized bowel and repair of the defect. A drain should be kept in abdomen and appropriate antibiotics should be administered. Explanation of the condition and the operation undertaken to the patient and her partner should be done as early as possible. Documentation of all the procedures in detail and filling the risk management form has to be done.