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Essay 282 - Laparoscopy

Posted by Ahmad A.
I would ask about her menstrual history and if it is regular or not and her last menstrual period. Also, I would ask about the previous deliveries and if she had previous cesarean sections. Also, I will aask about previous laparotomies in her past medical history, and if there is any difficulties or adhesions with previous surgeries. Also, I will ask about the previous other contraception and side effects were encountered. On the other hand I will ask about her partner and if he is willing to have other alternative permanent contraception like Vasectomy. Also, if she had a stable current relationship or not.

I would tell her that laparoscopic sterilization is considered one of the permanent contraceptive methods using different techniques like Filshie or Hulka clips, diathermy cutting of the both tubes or even bilateral salpingectomies. It is considered a day case surgery. Its failure rate of 1/200 and it may needs an additional contraception till the next period. The incidence of ectopic pregnancy in failed cases is high. I would tell her that in occasional situations we may fail to ligate the tubes and there possible option for laparotomy. Also, incase of complications like vascular or bowel trauma we may proceed to laparotomy. I would discuss with her the possible complications including general anaethesia used and other complications as result of verres needle, trocars and diathermy used with possibility of bowel, bladder and vascular trauma which may increase with previous abdominal scars. Full patients\' information has been provided and should be consented.

Complete setup of the procedure including manpower, skilled personnel, clinicians and equipments will significantly reduce the possible risk of vascular or bowel trauma. Using of Verres needle with spring to avoid bowel trauma after insertion. Different sizes of the needles can be offered according to the patient\'s abdominal wall thickness. Direction of the needle insertion at 45 degree towards the pelvis in lithotomy position an trendelberg with insertion of uterine manipulator may reduce the relative risk of trauma. Alternative sites of insertion of the needle or trocar insertion may be offered in case of high suspicious off intra abdominal adhesions in cases of previous surgeries. Palmer\'s site as midclavicular line in left upper lumbar quadrent is the least area may have bowel adhesions. Open laparoscopy or Hasson\'s technique is one of the alternatives to reduce the risk of bowel trauma. Also, available of different sizes of the 1st and second trocars with special blunt point and spring loader handle. Reduction of the diathermy used and if so, bipolar can be used instead as it reduced possible heat trauma for vascular and bowel. Illumination of the abdominal wall during insertion of the second and thirds trocars can avoid vascular trauma specially of inferior epigastric vessel. Insertion of the second trocars under vision will reduce possible injury. Also removal of the different trocars under vision will reduce possible herniation of bowel and strangulation through abdominal incisions. Closure of the different incisions with security of the fascia and subcutaneous fat.
Posted by shree D.
STA healthy 33 year old mother of 5 children has been referred to the gynaecology clinic because she requests laparoscopic sterilisation. Her BMI is 27kg/m2. (a) Which information would you obtain from the history? [4 marks]
Relevant history includes types of contraception used previously and their success. I would make sure alternative contraception had been considered, and that the patient is sure that her family is complete.I would ask about the reason for sterilisation, history of sexually transmitted infections and stability in her current rellationship. Medical problems such as mysthenia gravis and previous surgery such as salpingectomy or Caesarean section are relevant points. I would clarify any medications she is currently taking, whether she drinks alcohol or smokes.

(b) What would you tell her about laparoscopic sterilisation? [6 marks]
She must be aware of alternative forms of non-permanent contraception. She must be counselled on the success rate of laparoscopic sterilisation (1:200 failure rate), the fact that it is irriversible and should she become pregnant there is a higher rate of ectopic. Reversibility operations are not availabl e on the NHS. She should be aware of the risks of bowel and bladder injury, the risk of wound haematoma, pain and the risk of laparotomy. She should be aware that she will continue to menstruate and will require contraception until her first period. She will not undergo the menopause.


(c) She has been counselled and listed for laparoscopic sterilisation. Evaluate the intra-operative measures to minimise the risk of visceral and vascular injury [10 marks].
Closed entry techniques used in Gynaecology involves the insertion of the Veress needle prior to the port. A disposable needle should be used, with a double spring to minimise injury to the viscera. This should be inserted perpendicular to the abdominal wall. The risk of damaging the visera is 0.6/100000, with vascular injury slightly lower. Two clicks should be heard, and a saline test performed to ensure that the Veress needle has not penetrated viscera. Holding the anterior abdominal wall has not been shown to reduce the rate of visceral or vascular injury. 20mmHg pneumoperitoneum during the insertion of ports should be established to minimise the risk of damage to viscera; this can be reduced to 15mmHg during the operation. Blindly inserting the laparoscopic port is also a recognised technique,althoguh associated with a higher failiure rate. A central incision through the thinnest part of the umbilicus hsould be made. This should not extend through the peritoneum, to reduce the risk of visceral injury. Inserting secondary laparoscopic ports under direct vision also reduces the rate of bowel and vascular injury.

The open Hasson technique can be used in those who have had previous midline laparotomies, and reduces the risk of vascular injury.

Other entry points include Palmer\'s point, suprapubic entry and pouch of Douglas.These may be considered in patients who have had midline surgery, but may potentially offer suboptimal views.

Positioning the patient head down in Lloyd-davis upon insertiing the central umbilical port also helps move bowel out of the pelvic cavity, thus reducing the risk of intra-operative bowel injury. however, this must be done with the anaesthetist\'s permission. Upon entry, moving the bowel out of the operative field using a blunt probe also minimises damage. Using bipolar rather than monopolar diathermy reduces the risk of damage to surrounding viscera. Laparoscopic scissors should be used under direct vision only, to prevent inadvertent damage to structures. If the extent of disease is severe, this may increase the risk of damage to surrounding viscera/vasculature-eg. endometriomas, malignancy, so conversion to laparotomy may be saafer.

The risk of visceral and vascular injury is higher in thin or obese patients, so aptient selection is also essential
Posted by H H.
A healthy 33 year old mother of 5 children has been referred to the gynaecology clinic because she requests laparoscopic sterilisation. Her BMI is 27kg/m2. (a) Which information would you obtain from the history? [4 marks
I would ask her of her last menstrual period and regularity of her cycle and wether she is using contraception and which type. I will ask her of her husband attitude and wether he accepts doing a vasectomy if she is not fit for sterilisation.I will ask her if she had any previous abdominal surgeries and of any previous pelvic infections for which pelvic adhesions were diagnosed by a previous laparoscopy.I will see regarding her wishes and if she is sure she won’t to have any more children.


(b) What would you tell her about laparoscopic sterilisation? [6 marks]
I will tell her that it is a day surgery and will be discharged same day unless complications occur, that she will have general anesthesia and through a minihole in her belly button we will enter the belly and pick up the tubes to occlude them so she won’t get pregnant again.I will tell her that the failure rate , meaning getting pregnant after this procedure is 1-2/1000(Filshi clip) and this can be an ectopic pregnancy. As she is overweight she will need to see the anesthetist to assess difficulty with intubation and also tell her that there is risk of failure of entery to belly by the laparoscope and that she might need a minilaparotomy to complete the procedure.I would tell her that there is risk of injury to viscera and blood vessels , risk of uterine perforation from uterine manipulator and maternal death in 1/12000 procedures.I will tell her that when she wakes from anesthesia there may be some discomfort ,shoulder pains and some vaginal bleeding.I will tell her of additional procedures that might be needed in case complicatios occur as colostomy needed. I will tell her that if she was using loop for contraception it will be left in place till next period ,to be removed. She may experience heavier periods if she was on the pill and she stoped them after the procedure for which she should not blam as pills are known to reduce menstrual bleeding.


c) She has been counselled and listed for laparoscopic sterilisation. Evaluate the intra-operative measures to minimise the risk of visceral and vascular injury [10 marks
Avoid doing or be cautious during doing lap sterilisation in women who have pelvic adhesions, multiple abdominal scars, obese or with abdominal distension as risk of intestinal injury is great. The person who does it should be experienced and knows how to deal with complications. The guarding tip of the verres needle should be cheked and its patency also cheked . One should check that the verres needle is intraperitoneal before doing pneumoperitoneum. If there is abdominal scars ,change site of insertion from base of belly button to Palmers point or use the open techique which has been shown to reduce vessel injury but not visceral injury.The trocar and canula are inserted after doing proper pneunoperitoneum and direction of insertion should be towards the pelvis. 2ry ports are inserted under laparoscopic vision. Bipolar cautery is better used than monopolar to limit tissue and visceral trauma. Instruments should be kept maintained and insulated to avoid electrical coupling and injury of viscera. Early intraoperative detection of injury and correction give best results.
Posted by dr neelangini G.
A healthy 33 year old mother of 5 children has been referred to the gynaecology clinic because she requests laparoscopic sterilisation. Her BMI is 27kg/m2. (a) Which information would you obtain from the history? [4 marks] (b) What would you tell her about laparoscopic sterilisation? [6 marks] (c) She has been counselled and listed for laparoscopic sterilisation. Evaluate the intra-operative measures to minimise the risk of visceral and vascular injury [10 marks].
a) I will take her menstrual history to rule out possibility of pregnancy & other menstrual disorders , her detailed obstetric history – stating nature of previous deliveries whether vaginal or by caesarean section, I would also like to take medical history associated with overweight like diabetes, hypertension, thromboembolism , cardiorespiratory disease, thyroid disease. Her drug history including habbits like smoking & alcoholism or substance abuse . Also current contraception method esp, estrogen containing pills , as this may aggravate thromboembolism. Any history s/o recent or past pelvic infection causing fever, vaginal discharge, pelvic pain or pelvic mass to be sought. History of previous abdominal or pelvic surgery & anaesthesia exposure in past.

b) I would like to counsel her & her partner regarding their views & knowledge about other contraceptive methods including vasectomy which carries less morbidity & mortality. I would explain her about the procedure that it is a day care procedure & her surgery will be done through a small incision taken below umbilicus. She will usually receive general anaesthesia with tracheal intubation. We will pneumoperitonise(put air or CO2 gas) in her abdomen – intraperitoneal as part of procedure . Though this is a day care procedure , it has its complications & failure rates . complications can be of anaesthesia & or of surgery , like bowel injury, major vascular injury , surgical emphysema, embolism . She being overweight is at more risk of embolism or bowel & vascular injury because of difficulty in passing trocar & cannula.I would like to counsel her about possibility of recanalisation in future as it is a permanent method of sterilisation , and chance of recanalisation success is better with laparoscopic procedure & when clip & ring is used rather than cauterisation.

c) Team approach with anaestheic consultant , medical consultant & expert Gynaecologist (laparoscopist) , experienced assistant & staff is must to reduce risk of complications. Good set up with modern instruments will add to more safety. Oestrogen containing pill user should stop their pills & go for other alternative contraception , one month before surgery to prevent embolism. Adequate pneumoperitonisation with verres needle will reduce trocar related injury, also direction of trocar is to be pointed towards pelvis I,e 45 degree to skin to prevent major vessel accidents. Preferably enema given before procedure & practice of nil by mouth overnight preoperative will help to prevent major injury to bowel. General anaesthesia with tracheal intubation is appropriate fo this surgery. If previous history of abdomino-pelvic surgery & difficulty in insertion of verres needle & trocar subumbilically then we should go for other sites like palmer point or open laparoscopic procedure.Use of optimum electrocauterisation & bipolar cauteryto prevent bowel damage . usmae of modified trendelenberg position will prevent damage to major vessels. Use of uterine elevator for better exposure of tubes will also help to reduce damage to major structures. Inserting secondary trocars under illumination can prevent injury to inferior epigastric vessels & while removing trocars – should be removed under vision to prevent herniation of bowel.

Posted by A S.
am
a) History taking is important to exclude current pregnancy by asking LMP , last time of unprotected coitus and any use of contraception . I will ask about obstetric history about mode of deliveries whether vaginal or abdominal and previous abdominal or pelvic surgeries as well as previous treatment of PID or STI .
Stability of relation with her partner if she has one .


b) The woman should be told that tubal sterilisation is a permanent method of contraception done under general anesthesia through occlusion of both tubes mostly by clips .
Common side effects of the procedure include shoulder tip pains , abdominal pains and distention . Serious side effects are infrequent (3/1000) and includes injury to bowel or bladder or major vessels . This may require other operative interference as laparatomy to correct the damage . The operative risks will be higher if she has previous abdominal surgery or history of pelvic inflammatory disease because of possible adhesions . She is overweight but not obese so weight related risk is not increased. Pregnancy risk is 1/200 life time and she should use additional method for contraception for 3 months after the procedure . Alternative methods of contraception will be discussed like long acting reversible methods . Some women regret their decision and 1% request reversal of surgery . Spontaneous pregnancy rates after reversal are low . Discussion with the anesthesiologist will be offered .

c) Intra-operative measures taken to minimize the risk of visceral and vascular injuries include ensuring all machines are working well maintained especially cautery instruments . Veress needle should be sharp and inserted at longitudinal skin only incision at the base of the umbilicus as this is the thinnest part of the abdominal wall . Insertion will stop once the needle is in the peritoneal cavity . Free flow of CO2 at low pressure is indicative of correct insertion .Avoidance of moving the needle prevents further damage to the viscera if it occurred . Insertion of the primary trocar under high pressure while the patient is in horizontal position is important . Hasson s approach of insertion of the primary trocar entails open insertion under direct vision then pulling the sutures to prevent gas leak during the operation.No significant difference was found between the 2 methods . Once the scope is inside the abd cavity the pressure will be reduced and inspection of the whole abdomen is done . Insertion of secondary trocars should be done away from known anterior andominal wall vessels by using transillumination . under vision and once the tocar pierces the abd wall it will be directed to the pelvic cavity . The camera man should adjust the working field to appear in the middle of the picture on the monitor . Bipolar cautery is preferred to monopolar if needed . Removal of secondary trocars should be done under vision to inspect bleeding injured vessel . In case of suspecting adhesions at the umbilical region alternative Palmer s point which is 3 cm below the left costal margin in the mid-clavicular line can be used . The insertion of nasogastric tube will reduce stomach injury in this case .

Posted by G. K.
History should entail questions regarding previous modes ofdeliveries i.e vaginal or caesarian, since caerarian sections are associated with an increase risk of bowel adhesion to the subumbilical area leading to increased risk of bowel injury.Simlarly history regarding other procedures such as a previous midline laparotomy should be inquired fo the same reason.Any history of splenectomy or splenomegaly should be ruled out since splenectomy is a contraindication for \"palmer\'s point\" entry into the abdominal cavity.
Patient should be thoroughly councelled regrding the procedure, emphasizing the fact that it is a premanent method of sterilization which is done by occluding the fallopian tubes by clips or bands.She should be told that it\'s a day procedure done under general anaesthtic and provivded there are no complications sustained, she can go home the same day after few hours of observation in the day ward.She should be made aware of the risks of the procedure which are injury to bowel and bladder which is .4/1000 and injury toa major blood vessel being .2/1000 requiring a laparotomy or blood transfusion.She should be apprised of the failure rate which is 1/200.She should be made aware of the fact that above mentioned risks are increased with previous abdominal surgeries.
To avoid the risks of visceral and vascular injury, it is important that the surgeon is appropriately trained and is familiar with the instruments to be used.Similarly the theatre nurses and assistants should be well trained as well.
Prior to the procedure, it is importat to make sure that the equipment is in working order.
Method of entry depends upon whether the woman has had any previous surgeries or not. I case of previous surgeries, Palmer\'s point entry or Hasson\'s techniqueis preferable. Otherwise the umbilical approach is acceptable. The baldder should be emptied before insertion of the veresse needle to minimize damage.The patient should be in horizontal position prior to insertion of the veress needle and the abdomen insufflated with enough CO2 to reach a pressure of 20 to 25 mm Hg as this is associated with less risk of visceral damage when the trocar is inserted.After insertion of the trocar, laparoscope shouldbe inserted and the abdominal cavity thoroughly checked to make sure that there is no damage to any blood vessel or bowel. all the other ports should be inserted under direct visualization.
The tubes should be identified and either the bands or clipsplaced on them for occlusion.After completing the procedure, all ports should be removed under direct visualization to rule out any bleeding vessels.Incisions bigger than 5mm should be properly sutured including the rectus sheath to minimize the risk of hernia formation.Postoperatively, the woman should be observed for a few hours to make sure that she\'s is stable before she can be discharged.
Posted by Sandhya P.
a)A history of the mode of previous deliveries and time since last delivery would be obtained . A history of her past and current contraceptive measures , last menstrual period, cycle duration & regularity would be asked. A surgical history regarding any previous surgical procedures & any postop wound infections would be asked. A medical history of any cardiac & respiratory compromise which may have implication to pneumoperitoneum created at laparoscopy would be asked as also any history of asthma or drug allergies. A history of hypertension or diabetes and the wishes of her partner would be enquired.
b)She is a young woman of 33 yrs and i would tell her the implications of sterilisation - that it is a permanent & irreversible method of contraception . She should therefore be very sure that she has completed her family and will not later regret the decision . I would explain to her that laparoscopic sterilisn is done by applying clips to her tube (Filshie Clips) . The type of anaesthesia would also be discussed . she would be told the details of the procedure that the laparoscope is inserted through small ports created through her umbilicus and another port through her lateral abdomen .I will tell her that during insertion or surgery there is a small risk of bowel or vascular injury & failure to gain entry may need laparotomy . The failure rate of lap sterilisn is 1in 200 and there is a risk of ectopic gestation if failure occurs. I would also tell her about alternate contraceptive options like IUD If she should wish reversal later she would be told that the success is low about30%.
c)The risk factors for injuries during laparoscopy are obesity, previous abdominal surgery, previous abdominal sepsis, IBD like Crohns all of which should be carefully evaluated by history and examination . Careful patient selection can help decrease injury. Surgical expertise is very important & procedure should be done by a surgeon experienced can avert most mishaps. Pre op bowel preparation in high risk cases should be done .appropriate entry technique is very important as most injuries occur on entry - use of Hassons method or Palmer point .Direction of trocars should be away from previous insertions . adequate pneumoperitoneum should be created and maintained . Instruments should be checked before surgery .Guarde point instruments should be used. Secondary ports should be inserted under direct vision. If the procedure becomes difficult early recourse to laparotomy .Early recognition of injury and repair should be done with help from surgical experts if needed. Appropriate use of laser and diathermy to control bleeding should be used. Good post op care is also neede for recovery . Thrombo prophylaxis based on patient risk profile is needed.
Posted by Sowmithya B.
A. Her chance of pregnancy is assessed by asking about her first day of last menstrual period and contraception. Her last child birth should be enquired as laparoscopic sterilisation cannot be offered in immediate puerperium. History of previous abdominal surgery which is likely to increase the risk of intraoperative complication like bowel injury should be asked. Enquire about any gynaecological complaints like menorrhagia would make other methods of contraception like levonorgestrel releasing intrauterine devices better option than sterilisation.

B. The risks and benefits of laparoscopic sterilisation have to be mentioned. The risk associated include bowel injury (0.4-3/1000), major blood vessel injury (0.2-1/1000), injury to urinary tract, injury to omentum, preperitoneal insufflations and surgical emphysema and port site hernia formation as long term complication. The women also should be counselled about that vasectomy has lower failure rate (1/2000) than tubal ligation and lower complication rate. The failure rate associated with sterilisation is 1/200 and after 10 years it is 2-3/ 1000.when there is a failure risk of ectopic pregnancy will be increased. Hence in case of missed periods with lower abdominal pain and slight vaginal bleeding she should seek medical help. But she also should be told that risk of ectopic pregnancy is lower among sterilised women than compared to non sterilised women. Availability of other long term reversible contraceptives should be informed in term of failure rate as cumulative pregnancy rate as 2% after 12 years use with cu T 380 and 1% for LNG IUS after 5 years of use. Effective contraception should be used until the procedure and continued till next periods. Even though sterilisation is meant to be a permanent procedure the reversal of sterilisation should also be discussed. The successful intrauterine pregnancy rate of 30 – 90% and ectopic pregnancy rate of 0-7 % following reversal should be informed. She should also be informed that sterilisation will not cause menorrhagia especially when it is performed after 30 years. Written information should be given.

C. The instruments and equipments should be in good condition and the surgeon should be appropriate trained and should have done at least 25 laparoscopic sterilisation under supervision before proceeding to do it independently. The nursing staffs and anaesthetic assistants should be appropriately trained and aware of complication. The patient should be made to lie flat at the time of entry to reduce the risk of bowel and vessel injury. The table should be straight. Bladder should be empty. Abdomen should be palpated for any mass. Vertical incision should be made at the base of the umbilicus as this is the thinnest area in abdomen. Disposable verres needle which is sharp and has good and tested spring system should be used. The verres needle should be inserted at right angle to the skin. Audible double click should be noted as it passes through rectus sheath and peritoneum. The needle should not be pushed further after we have entered the peritoneum. Lateral movement of the needle should be avoided as we are likely to convert a small needle injury to bowel or blood vessel to complex tear. 2-3 ml of normal saline should be injected and assess for free flow. There should not be return of water on aspirating back. On insufflations initially there would be low pressure (below 8 mmHg) which again indicated that the needle is with the peritoneal cavity. Once entered the laparoscopy should rotated over 360 degree to look for any injuries in form of haematoma or tear. If two attempts at insertion of verres are futile it is better to use palmer’s point for insufflations and visualisation in the absence of previous abdominal surgery at this area and splenomegaly. Or else open method (Hasson’s technique) should be employed. The secondary ports should be inserted only after visualising the inferior epigastric arteries and their veins. The ports should be inserted under visualisation.
During the procedure use of diathermy is associated with increased incidence of occult bowel injury and hence care should be taken to avoid the same. Post operatively information about the use of diathermy should be given and advised to seek medical help in case of pain abdomen, fever or general unwellness. The trocar should also be removed under visualisation to rule out through and through injury to bowel adherent to umbilicus as the risk of bowel adherence to anterior abdominal wall is 0.5% even in patients who has not undergone any abdominal surgery and 20% with lower abdomen transverse incision and 50% with mid line incision. Proper assessment of every patient and proactive approach to avoid the complication will definitely help to reduce the same.
Posted by Farzana N.
a) Obtetric history is obtained about the mode of delivery, as previous c-section or a midline abdominal scar would increase her risk of having intra abdominal adhesions, age of the youngest child.Menstrual history about her LMP,regularity of cycle. This is to ensure that sterilization is not performed in the luteal phase of her menstrual cycle,avoiding risk of pregnancy. Contraception history is taken and she is advised to continue contraception till sterilization.It should be ensured that the woman is certain of her request for sterilization.
b) Adequate and clear information should be given about the procedure.She should be informed that it is a permanent method and risk of failure is 1 in 200.In cases of failure there is a high risk of ectopic pregnancy.If she wants reversal at any time,the success rate is only 30% and that reversal procedure is not funded by NHS.
Laparoscopy is a day case procedure done usually under general anesthesia.Tubes are occluded, using Filshie clips,which is the recommended method.The procedure is associated with complications such as risk of bowel (0.4/1000) or vessel (0.2/1000) injury.at the time of entry.Late complications such as hernia formation may occur at entry ports.In case of inadvertent bowel or bladder injury,a laparotomy may need to be performed.
Postoperatively she may have abdominal discomfort and shoulder tip pain.Written information should be provided and clearly documented.
c)The most effective way to reduce the risk of visceral and vessel injury is to optimize insertion of primary trocar and canula by following safe entry technique.Surgeon should have appropriate training and experience.
Operating table should be horizontal in the beginning of the procedure.Abdomen should be palpated to check for any masses and position of aorta.
Entry to abdominal cavity can be achieved by closed or veress needle entry technique ,where abdominal cavity is insufflated with carbondioxide before inserting primary trocar and canula.or open(Hasson) method ,where the primary trocar may be inserted into peritoneal cavity under direct vision.Open technique reduces the risk of vessel injury but does not reduce the risk of bowel injury.but it would be recognised at the time and repaired.
RCTs comparing the open and close entry technique have not indicated a significant safety advantage to either .
Alternatively Microlaparoscope inserted at palmars point allows insertion of subumbilical trocar under direct vision, except in cases of previous surgery in this area or splenomegaly.
Veress needle is checked to ensure that spring loaded mechanism is working.Lower abdominal wall is stabilized so that veress needle is inserted at right angle to skin and pushed till a double click is heard.Excessive movement of the skin is avoided as it may convert a small needle point injury in the wall of the bowel or vessel into more complex tear. Pneumoperitoneum of 20-25 mmHg should be created before inserting primary canula.and reduced once safe entry is achieved.Secondary port inserted under direct vision .to ensure the inferior epigastric artery is away from the entry point.These should be removed under direct vision so that any hemorrhage can be observed and treated.
Posted by Manoj Babu  R.
(A)

A detailed history of any previous abdominal surgeries, inflammatory bowel disease and appendicitis, PID and peritonitis should be obtained. This will enable us to adequate precautions while doing surgery or to consider alternative options

(B)

I will tell her about the permanent and irreversible nature of the procedure and it is done by applying a special clip on both her fallopian tubes. The failure rate is about 1 in 200 and if a pregnancy occurs she is also at risk of ir being in the tubes. The risks of serious complications like bowel injury, major blood vessel injury and injury to the urinary tract should be told even though they are rare, less than 1 in 1000. Other problems like shoulder tip pain, long term risk of hernia at rhe port sites also should be told She is also at a higher risk as her BMI is high. She should also be made awre of the need of laparotomt if any difficulties arise. She should be told that it a mini-laprotomy. I will also tell her about the alternative procedures like hysteroscopic sterilization and intrauterine devices.

(C)


Most of the intaoperative injuries occur at the time of entry into the peritoneal cavity. The table should made horizontal, at time entry to minimize the ventillatory difficulties and to avoid change in the position of aortic bifurcation. As she is obese either an open technique (Hassan’s) or Palmar point entry is preferred, especially if she has previous laparotomy to minimize the risk of injury to bowel and major vessels. It has been found that the blind verres technique is riskier in abese women and if it is used is should be inserted vertical to the skin to avoid subperitoneal insufflation.

The skin incision should be made exactly at the lower border of umbilicus. Once the rectus and peritoneum is opened and visualizing the bowel or omentum the blunt tochar is inserted. Look for any adhesions after inserting the laparoscope.

While inserting the side trochar one should go lateral to the rectus muscles if there is difficulty in visualizing the inferior epigastric artery, to avoid injury to it and the tochar should be directed medially. Then look for any evidence of bowel injury or any retroperitonel haematoma before proceeding with the sterilization.



Posted by S M.
SM reply.
a)
I would enquire about the reason why she has chosen this method of contraception over other methods.
I would like to ask her about her LMP, menstrual cycles, any dysmenorrhoea and contraception details used till date. I will enquire for details about childbirth, if cesarean section was required and whether her children are well and healthy. I would enquire about significant past history like VTE, chronic diseases like hepatitis B, any drugs intake, smoking and allergies. I will ask about any laparotomies in the past. I will enquire about her last cervical smear date and report. I would like to ask her if her partner would like to participate in this discussion.


b)
About laparoscopic sterilization, I would tell her that it is a permanent method of sterilization. I will confirm if vasectomy as an option has been discussed. If she is sure of her choice of laparoscopic sterilization, I will tell her that the surgery means that she cannot have another pregnancy. I will draw to explain the same . It is best to do the surgery in the follicular / proliferative phase of the cycle ,when pregnancy can surely be ruled out. The risk of failure is 1in 200.If she does get pregnant , the chances of ectopic pregnancy are upto 70%,depending upon the method used. General anaesthesia is usually used .She will have small abdominal incisions at the umbilicus and both iliac fossae. Usually , Filshie clips or Falope rings are used . Hulka clips have higher failure rates . Frequent risks like soreness /pain in abdomen may occur . Mild analgesics may be required. Serious risks of need for laparotomy due to visceral or vessel injury , will be explained . Menorrhagia is not common after sterilization in women of her age. She may resume routine activities after a week . If she feels unwell , feverish or has severe pain at anytime after the surgery , she must report to the GP immediately. I will advice her to continue her contraceptive or use barrier contraception until her next menses. I will give her contact numbers of the hospital /specialist nurse and written information regarding the surgery. I will tell her that though reversal of tubal sterilization is technically possible , IVF /ICSI is not funded by NHS.

c)
Intra-operatively , it is important to ensure an adequately trained team for the surgery. Adequate anaesthesia is imperative for a safe surgery. Before the surgery , the woman’s abdomen must be palpated for any mass and to feel for the aorta. Bladder must be evacuated to prevent bladder injury . Patient must be kept flat . The veress needle must be a disposable one with a sharp tip and good spring action .The Veress needle must be inserted at 90 degrees, through a vertical incision made intraumbilically. This prevents surgical emphysema.2 clicks must be heard or saline can be used to confirm intraperitoneal placement. Lateral movement of the Veress must be avoided to avoid bowel injury. Alternate entry point like Palmer’s point , 3 cm below left costal margin may be considered if she has undergone previous laparotomies. Hasson’s open technique may help prevent injury to intestinal adhesions.Intra- peritoneal pressure of 20-25 mmHg ensures no injury occurs to abdominal contents . Once the laparoscope is inserted , intra peritoneal viscera/vessels must be checked for any obvious injury. Trans illumination must be used to identify the lateral vessels before inserting additional ports.These must be done under direct vision . Bipolar cautery must be used, when required , as this is safe .Proper insulation must be ensured . After the surgery , hemostasis must be confirmed and all ports must be removed under vision to prevent herniation of intestine /omentum. All central ports above 10 mm and lateral ports above 7mm must have closure of sheath to prevent hernia in future.
Posted by Manoj M.
A healthy 33 year old mother of 5 children has been referred to the gynaecology clinic because she requests laparoscopic sterilisation. Her BMI is 27kg/m2. (a) Which information would you obtain from the history? [4 marks] (b) What would you tell her about laparoscopic sterilisation? [6 marks] (c) She has been counselled and listed for laparoscopic sterilisation. Evaluate the intra-operative measures to minimise the risk of visceral and vascular injury [10 marks].

a) Information about that she is definite about the decision and that she is completed her family beacuse tubal sterilisation is a permanent method of contraception and to avoid any regret in future.
Her current method of contraception and her last menstrual period(LMP) to exclude underlying pregnancy.
Her past obstetric history mainly the mode of delivery because previous caesarean sections(cs) will increase the risk of laparoscopic injuries with adhesion (especially if any cs performed with midline abdominal entry)
She is aware of alternative methods of contraception and understands tubal sterilisation will not alter her current menstrual pattern.

b) She should be told the procedure is called tubal occlusion and done under laparoscopic approach which involves a keyhole surgery under general anaesthesia and steps of procudure with information supported with written leaflets.
She should be explained regarding alternative procedures available including vasectomy for her partner which is done under local anaesthesia with less failure rate of 1:2000, Levonorgesterol intra uterine systems, Depo injections, oral contraceptive pills, implant devises.
She should be explained tubal sterilisation will not alter her menstrual pattern and she will need to contine her cervical screening as recommended.
This procedure is usually done as a day surgery procedure and she is most of the time able to go home the same day.
This procedure has a failure rate of 1:200 which means she can get pregnant even after the procedure and associated with a 5% increased risk of ectopic pregnancy.
Any Laparoscopic procedure is assoicated with immediate risk of bowel, renal tract or vascular injury and later risk of port site hernias.
She should be told about the limitation of reversal of procedure in future and may need to pay money for the same.
She will be told that she will have a pregnancy test to exclude pregnancy prior to tubal sterilisation although a early pregnancy may be missed by the same and for the same to continue her current contraception right upto the sterilisation and untill her next period to ensure she is protected contraceptively.

c)The surgeons performing the procedure should be familiar with the instruments and have adequate training or performed under supervision to minimise the risk of visceral and vascular injury.
Both open and closed laparoscopic entry has almost similar risk of visceral and vascular injuries.
Prior to any entry the patient\'s abdomen should be palpated for any masses and also palpate for abdominal aorta so as to avoid or minimise any visceral and vascular injuries.
Closed entry is done with tested verres needle with good spring action (disposable needle) directed perpendicular to the skin with the patient should be horizontal on the table.
Common site of entry is umbilical unless with previous midline incisions other sites like palmer point of entry to minimise visceral and vascular injury.
The verees needle should be at right angle to the skin and just pushed sufficiently to penetrate the fascai and peritoneum with 2 audible clicks and avoid any excessive lateral movements to avoid injuries and extension of injuries to vascular and visceral structures.
CO2 should be insufflated to an intraabdominal pressure of 20-25mm of Hg for first port entry to avoid vessel and visceral inury, and the subsequent port introduced under direct laparoscopic visualisation.
Primary port should be inserted through thinnest part of abdomen i.e. umbilicus at 90 degree to skin and insertion stopped immediately as the trocar in the abdomen to reduce risk of visceral and vessel injury.
Insertion of secondary port should involve visualisation of inferior epigastric vessesl and avoid this in the entry path and maintain abdominal pressure of 20-25mm of Hg.
If suspected primary port injury to any structure, this should be visualised through a secondary port and also removal of secondary ports under vision and removal of primary port under vision will exclude visceral and vessel injuries.
Documentation of events and incident reporting should be done in the event of visceral and vessel injuries as this will help in understanding these situations and improve clincal care.
Posted by S M.
a) I would find out her reason for requesting sterilisation and whether she knew it was considered a permanent procedure. This is relevant since she may not know that it is permanent and may wish to have more children in the future. I would determine whether she knew of other contraceptive methods. I would find out her present contraceptive method, whether she was currently sexually active and the last menstrual period. This is important to determine the possibility of a current pregnancy. I would ask about previous abdominal operations such as caesarean section which because of adhesions would increase the risk of bowel injury during the laparoscopic sterilisation. I would ask about her past medical history such as diabetes, heart disease or thromboembolism. These would increase the risk of complications and another method of contraceptive may be more suitable. A history of pelvic inflammatory disease may indicate damaged tubes with adhesions which would make the laparoscopic sterilisation difficult or impossible. Another method of contraceptive may be advisable.

b) I would tell her that laparoscopic sterilisation is considered a permanent procedure. It may be reversed but this is unlikely to be successful. It is done as a day case in hospital and she should be allowed home on the same day. It is done under a general anaesthetic. Two small cuts are made on the abdomen, one in the belly button and the other just above the bikini line. Carbon dioxide gas is put through the belly button to help us to see in the abdomen and to put instruments in safely. The laparoscope is put through the belly button and a clip is applied to each fallopian tube to prevent the pregnancy from occurring. There are risks with the operation. Serious risks are injury to the bowel, urinary tract or major blood vessels. If this occurred, a laparotomy would be necessary which involves a larger incision on the abdomen to allow for the repair of the injured organ. Other risks are failure to enter the cavity, failure to put the clips on the tubes. There is also a risk of 1 in 200 that the procedure it self will fail and a pregnancy would occur in the future. If she became pregnant it may be an ectopic pregnancy which is a pregnancy in the fallopian tube. Ectopic pregnancy may be treated by medical treatment of surgery. Frequent risks of laparoscopic sterilisation are shoulder tip pain and abdominal brusing.

c) The operating table should be horizontal and abdomen palpated for masses and the position of the aorta. The veress needle should be checked to ensure it is sharp and that there is a good spring action. This is valuable since it ensures that the needle will work effectively. An appropriate entry technique should be chosen to minimise injury. The veress needle should be vertically inserted in the thinnest part of the abdominal wall which is the umbilicus. This is valuable since it reduces the risk of injury. The needle should not be moved around since movement may enlarge small injuries. If there have been previous abdominal operations then Palmers point should be chosen as the site of entry. This would be of great value to minimise risk of inserting the veress needle or trocar into bowel attached to the umbilicus. Carbon dioxide gas insufflation should be done at 20-25mmHg to distend the abdomen for visualisation and safe entry of primary trocar. This pressure is effective at minimising risk of injury to blood vessels. The primary trocar should be inserted at the umbilicus and at 90 degrees to the skin. On entry into the abdomen the laparoscope should be used for 360 degree view of the abdomen to identify any injuries that would require immediate repair. Secondary trocar should be inserted and removed under direct vision. This is valuable since it will identify immediately any injuries. If the secondary port is inserted into the lateral aspect of the abdomen, the inferior epigastric vessels should be identified and the trocar inserted lateral to the vessel. This is valuable approach to prevent damage to the inferior epigastric vessels.
Posted by Mark D.
MARK.D


a)

I will take menstrual history ,regularity and LMP.I will enquire what method of contraceptions is she currently using whether she has any problems with it and ask why would she want to change it.
I will ask past history of abdominal surgeries like cesarean sections or appendisectomy. I will check their indication( ruptured appendix would give more adhesions than elective) and any difficulties encountered during them.
I will ask if she has any drug allergies and if she smokes. I will check for any past history of PID ,ectopics or endometriosis where more adhesions are expected.


b) I will tell her that this surgery involve occluding both fallopian tubes with clips with the intension to prevent fertilization and future pregnancies. It is a key hole surgery done under general anesthesia as a day care surgery.It is considered parmanent.It has a failure rate of 1/200.It involves common problems like shoulder tip pain, abdominal pain,in the next 2-3 days which would resolve with analgesics. Surgery involves serious risks like injury to bowel,bladder and blood vessels of 0.5 to 0.7/1000 .There is a risk that the surgery may have to be converted to laprotomy in 1/10,000 cases either for difficult procedure or for repair of such injuries and very small risk of death(1 /12000).Some women do complain of heavy periods after this surgery but there is no evidence for this. I will provide written information regarding the procedure.
Though this is considered irreversible procedure I will tell her that the success rates of reversal procedures vary from 40-65%. I will provide information on alternatives like long acting reversible methods of contraception like Implanon, depot progesterone injections and IUCDs. I will also tell her about male steralisation and that it is safer, quicker, less morbid, lower failure rate(1/2000) and done under local anesthesia.
c)

The operating table should be horizontal ,bladder emptied and veres needle passed at right angles to the abdominal wall through a incision in the base of umbilicus. This incision is recommended because the abdominal wall is thinnest at this portion and thus injury to underlying aorta is low and risk of emphysema is also low. However in very thin women the distance from skin to aorta can be as low as 3 cm and this may not totally prevent the vascular injury. In obese women the distance may be more and emphysema may occur.
The needle should not be advanced further after the double click is heard and swinging of needle avoided. Occasionally the spring may be ill functioning or clicks may not be heard. Saline drop test is recommended (instillation of 5 ml saline and not being to reaspirate it) to confirm intraperitoneal placement.If in bowel then aspirate will give feacal contents and raise suspicion of intraluminal placement in bowel. However in cases where needle is in the empty part of bowel it may not be able to aspirate the saline or bowel contents and injury may go unnoticed.
In cases with previous laprotomies alternative entry method is chosen.but there is 2% incidence of bowel or omental adhesions below the umbilicus in patients with no previous surgeries and where bowel injury may still occur. Entry at palmer’s point prevents injury in 76% cases and is easy technique.However may cause injury to enlarged spleen and rarely there may be adhesions at this point also.
Entry by Hasson’s open method can be used .This prevents bowel injury in 89-94% cases and safe for beginners and picks up bowel injuries easily. The disadvantage is that the port may be bigger than wanted and lead to continous leak of gas during surgery and very rarely make a big injury by scalpel at entry to a adhered bowel.
Initial pressure should be maintained 25mm during entry of trocars to keep the distance of aorta and viscera from skin to a maximum.However may causes respiratory compromise by pushing the diaphragm upwards.
The lateral port should be sited under vision and transillumination to avoid the inferior epigastric vessels, but this may not be clear in obese women.
A 360 degree panoramic view of abdomen should be taken at entry as the trocar could have caused a through and through injury in the bowel adherent below the port point.
Injury can occur with diathermy. Hence surgeon should be familiar with principles of diathermy and instruments checked and bipolar preferred over unipolar cautery.
If anytime after entry there is increasing hypotension and bleeding from aorta is suspected immediate laprotomy should be undertaken.however small vessel injuries may not cause slow ooze and delayed compromise. After surgery trocars should be removed under vision because the trocars may have compressed the bleeders and they may go unnoticed. The pneumoperitoneum reduced to decrease the possible tamponade effect on vessels to check for bleeders at port areas.
All port above 7 mm should be closed with vicryl for rectus sheath to prevent herniation . howvere herniation may occur if other pricipitaing factor like infection, chronic cough are present and rarely from the smaller port also.
Posted by Dr Dyslexia V.
A healthy 33 year old mother of 5 children has been referred to the gynaecology clinic because she requests laparoscopic sterilisation. Her BMI is 27kg/m2. (a) Which information would you obtain from the history? [4 marks] (b) What would you tell her about laparoscopic sterilisation? [6 marks] (c) She has been counselled and listed for laparoscopic sterilisation. Evaluate the intra-operative measures to minimise the risk of visceral and vascular injury [10 marks].

a.
Information which include of her reasoning of having a potentially irreversible form of contraception should be taken. Her emotional and social status should be also taken as a divorcee, who potentially be remarried and would like children again.
Her menstrual cycle and her current from of contraception. Her last unprotected coitus and her planned procedure. Her reason for not wanting other reversible form of contracption should aslo be obtained.
History of pelvic inflammotory disease, inflammotory bowel disase, endometriosis or previous abdominal surgery must be gathered for potential complication from procedure such as bowel injury.


b. I would inform that it is a form of key hole surgery which is relatively safe and routine. It has the advantage of being more cosmetic than a minilaparotomy, speedier recovery from procedure,
shorter hospital stay and a more informative procedure as the whole abdomena and pelvis could be visualised.
there is the aspect that complication such as bowel injury, bladder injury, vascular and thermal injury could occur but relatively rare .

I would inform that sterilization is a irreversible form of contraception and its failure rate is about 1:200 in. And in the event a pregnancy occurs after sterilization it more likely to be an ectopic pregnancy.

And there could be a possiblities of converting the operation to a laparotomy in the event the sterilization couldn\'t be done or encountering a complication.


c. Intraoperatively the procedure should be done a by a competent and trained personnel. The assistant, supporting staffs and equipments should be of proper standards and to be checked by the surgeon before beginning the procedure. Bladder must be catheterised as the veress needle could puncture it during insertion.
The veress needle must be examined of its spring action and if the needle is hollow. After insertion of the needle the safety test done as to aspirate the veress needle content . The carbon dioxide insuuflator pressure checked which shoul be less than 7 to demonstrate it is in the abdomen and not impeded by any structure. Afater insufflation of 20 to 25 mmHg then trochar is inseterted to put in the telescope. By this pressure the chances of hitting the bowel will be less. After inserting the telescope a 360 degree view done to look for bleeders or any fecal matter in the abdomen. The subsequent port could be entered under direct vision by the telescope and care taken to avoid the the inferior epigastric artery which is lateral to the lateral umbilical ligament.
the camera entry could be viewed by the port entry to look out for through and through bowel perforation.
The ports should be removed under direct vision.
Posted by Ron C.
A.
I want to know what her current method of family planning is, whether she is aware of all alternative methods of family planning (including male sterilization), why she has opted for sterilisation and what she has discussed with her husband. I’ll also enquire regarding her cycle regularity and in particular heave menses. I’ll ask about any medical problems and use of medication, as well as allergies.

B.
I’ll tell her that it is irreversible as success rates of re-anastomosis are poor. The reliability is good, but depending on technique there is still a failure rate up to 1-2:100 over 10 years time, and if pregnant, ectopic pregnancy is more common. The procedure will be done as a day case under general anesthesia. Like any surgery there is risk for infection, bleeding, thrombosis and anesthetic complications. Additionally risks are accidental injury of bowel, bladder or great vessels, and if so, laparotomy will often be necessary for repair, which may happen as often as 1:300 procedures.

C.
All equipment needs to be checked prior to surgery, including the spring mechanism of the verres needle. Prior to insertion the abdominal wall will be lifted up and the needle directed towards pelvis. While going through layers pay attention for 3 “clicks” and resistance. A Palmer’s test (saline flush, aspiration to check for blood etc, and letting saline go through freely) should confirm proper placement. Insufflation is started on low flow and pressure should not be higher than 10 mm Hg. needle is removed once pressure is 25 mm Hg, abdominal wall lifted again and first port introduced slightly directed towards pelvis. Prior to reconnecting the gas, visual confirmation of being in the abdominal cavitiy. The other port(s) should be introduced under vision. Instrument handling always under vision. Alternative to this approach would be a semi-open approach (ie incision till rectus sheath, then opening sheath and entering abdomen under vision for placing port and insufflation.
Posted by syeda sajida M.
a) I would like to know the reason for her request. Is she in a stable relationship? I will take complete menstrual history specifically history of menorrhagia, premenstrual syndrome, dysmenorrhea, and also LMP.
It is important to know the mode of previous deliveries and time of the last child birth and whether all the children are alive and well. Detailed contraceptive history, current method of contraception and result of previous cervical smear should be asked. Detailed past medical and surgical history, any gynaecological problem like PID and endometriosis to be asked.

b) It is one of the permanent method of sterilisation. It can be done as a day case, associated with less post-operative pain, early mobility and quick recovery.
I will explain the procedure and small risk of failed access and the need for mini laprotomy to complete the procedure as well as risk of bowel injury 0.4/1000 and vascular injury 0.2/1000 during the entry and procedure. In that case she may need laprotomy and further management.
Filshies Clips will be applied one each on both tubes. Post-operatively she may feel mild abdominal pain and shoulder tip pain for which she wiil be given proper analgesia.
I will explain other methods of long term reversible contraceptive methods and also provide information about vasectomy which can be done under local anaesthesia.
I will inform her the risks of anaesthesia, failure rate of tubal ligation 1/200 as compared to vasectomy 1/2000 and small rosk of ectopic pregnancy, but this risk is less than in those women who don\'t use any contraception.
I will advise her to continue her present contraception till procedure and then to continue till next period.
I will give her written information.

c) Proper functioning of the equipment and good assistance is very important to reduce the chances of complication. Empty bladder and palpation of abdomen for aortic pulsation and any mass will reduce the chance of vascular and visceral injury.
Sharp Veres needle and functioning spring loading mechanism OR preferably use of disposable veres needle will reduce the chance of any entry related injury. I will take longitudinal incision at the base of umblicus and then insert the veres needle straight and I will not push further once I will hear the two clicks and later not to move the needle will all help in reducing the chance of any visceral and bowel injury.
I will also perform palmer\'s test and pressure less than 8 mm of mercury and good flow of gas will all indicate that I\'m in the right intraperitoneal position.
Intra-abdominal pressure of 20-25 mm of mercury should be created before the insertion of primary tocar as it will give the distance of about 5 cm in between abdominal wall and viscera and reduce the chance of injury. I will insert the primary tocar in a controlled manner 90 degrees through the base of the umblicus as it is the thinnest part of the anterior abdominal wall.
Proper visualisation of the abdominal cavity around 360 degree once laproscope is introduced will help in identifying an injury, if still there is doubt visualisation of primary tocar side by 5 mm telescope inserted through secondary port will reduce the chance of bowel and visceral injury.
All secondary ports should be inserted and removed under direct vision so that if any vascular injuries are identified can be dealt with appropriately.
If there is a previous abdominal surgery there is a chance of adhesions so palmer\'s point to be used for primary entry. This point can also be used if there are 2 failed attempts for veres needle insertion.
Reduction of pressure to 15mm of mercury before the operative procedure and to place patient in Trendelenberg position will also reduce the chance of bowel injury.
Bipolar diathermy to be used if needed and before using it checking the whole length of the instrument with the telescope that it is not touching any bowel.
If there is any doubt to inform patient to report in case of abdominal pain, distention and pyrexia.
Posted by J P.
a.I will equire about the menstrual history including whether it is regular or not,last menstrual period because sterilization should be avoided in luteal phase to avoid possibility of early pregnancy.Obstetric history including number of previous conceptions,mode of delivery and time since the last child birth will also be enquired.History of recent PID will also be enquired since this may precipitate infection and viscus injury.Contraceptives if any used will be enquired and asked to continue till the next cycle after sterilization.Past surgical history if any [caesareans or any other] will be enquired to assess the increased risk of viscus or vscular injury.I will also like to know about the awareness of this method as it is a permanent method and also whether partner is involved in decision making.
b.I will tell her that it is a permanent method of contraception.I will explain the procedure as it involves a small cut in navel and a telescope is inserted to view the tubes and the sterilization is usually done by occluding the tubes by clips.It is usually done as a day care procedure under GA.Failure rate is 1 in 200 of the cases.Frequent risks are infection.shoulder tip pain due to pneumoperitoneum .Serious risks may be injury to vessels and viscus which may be increased in obesity,anaesthetic risks and return to laparotomy.The patient must continue contraception [OCP] till next menses .If conception is desired later ,recanalisation can be done which carries a success rate of 30-90% but not funded by NHS.Alternate methods of contraception like vasectomy ,injectables ,IUS and implants will be explained.Vasectomy has a failure rate of 1 in 2000 cases and fewer complications as it is done under local anaesthesia.Written information will be provided.
c.The operating surgeon and staff should have the necessary expertise. The equipment should be checked before surgery.Cautery if used should be bipolar.Since her BMI is high,Palmers point[3 cm below left costal margin in midclavicular line]or open technique should be employed to minimize the risk of injury.Palmers point is of great use except in cases of splenomegaly or adhesions in that area due to surgery.If closed technique is used, veress needle to inserted vertically stabilizing the abdomen through the incision at the base of the umbilicus .The needle should be sharp and lateral tilt avoided to prevent converting small injury to a large one. Double audible click will ensure correct localization of needle.Pneumo peritoneum of 20-25 mmHg should be created before insertion of trochar and reduced to 15 mm after insertion.This pneumo peritoneum creates a splinting effect which will reduce the risk of injury..The correct localisaton can be detected by palmers test or saline drop test..
All the secondary ports to inserted under direct vision.Inferior epigastric artery which is of particular risk to be visualized before insertion of secondary port.Deep epigastric arteries injury can be avoided by placing the incision lateral to the lateral edge of rectus sheath. If there is suspicion of bowel injury another port to be inserted for the visualization.
Posted by Neelam A.
I would ask what she knows about this operation. A menstrual history is important to ask her last menstrual period to rule out her being pregnant, any irregular cycles or history of heavy periods. A check should also be made to know age, sex and health of children. Contraception history should also be taken into consideration. I would also take sexual history to know whether she is in stable relationship or no partner. In surgical history, any previous abdominal surgery such as caesarean section or appendisectomy would increase her risk to have complications to laparoscopic surgery. I would also enquire her past or current medical history to assess her fitness to operation and anaesthesia including history of pelvic inflammatory disease. Cervical smear status should also be checked. Current medication history along with known allergy should be documented as well.
I would tell her that this procedure would be done as a day case procedure under general anaesthesia. She needs to come fasting on the day of procedure. It is a key holes surgery. I will explain the operation in details including complications, frequently occuring: shoulder tip pain, bruising to incision sites; seriously occuring: damage to bowel, blood vessels and uterus. I would also explain the need to undergo laparotomy (if any complications arise or failure to do operation laparoscopically) or blood transfusion. I will discuss failure rate 1:200, and if this fails then pregnancy will likely be ectopic. I will also discuss other long term reversible contraceptions in addition to low risk vasectomy option. I also highlight that this operation is permanent method and reversal is not available on NHS. If she still wishes to undergo this operation, I will take the consent and give a copy of this. I will also provide her an information leaflet. I will document every thing in her notes. I will also tell the importance of using contraception until next period after operation. I also warn her the possibility of her having heavy periods once she has stopped combined oral contraceptive after this operation.
It should be done by trained experienced gynaecologist as there were more bowel complications when this operation was performed by tranees.
Aii equiments should be checked before the operation.
Risk assessment should be done before udertaking this procedure. Previous abdominal surgery will increase the risk of trauma to bowel or blood vessels. Either Hasson technique (open laparoscopy) or Palmer site should be chosen for Verres needle entry. Open laproscopy has been shown to be associated with less incidence of vessels injuries compared to closed laparoscopy, however no reduced cases of bowel injuries with open technique.
Vaginal examination should be done to assess whether uterus is anteverted or retroverted before instrumenting the uterus to avoid uterine perforation.
Bladder should be emptied before putting verres needle as it would avoid trauma to bladder.
No head tilt, while inserting ports or needle.
Direct trocar entry is associated with increased cases of bowel or vessels injuries, hence it should not be practiced.
Disposable verres needle is associated with reduced complications. It should be hold in pen holding position. Avoid any movement of verres in abdominal cavity as it change simple injury to zig-zag injury. Confirmaton of verres in abdominal cavity can be done by Palmer method or free flow entry of gas or low gas pressure (<10). Pressure should be set at 20-25 at the time of port entry as it reduces the risk of trauma.
Guarded trocar entry and high pressure reduce the chances of soft tissue trauma.
A search should be made with laparoscope in all directions to see any evidence of soft tissue trauma.
Secondary ports insertion and removal should be under laparoscopic vision. Secondary port should be inserted lateral to inferior epigastric artery.
Laparotomy should be performed in cases of suspected haemoperitonium or bowel perforation.
Pressure should be reduced to 15 at the time of surgery.
Posted by S D.
a) Detailed history about LMP, menstrual cycle; Current contraception and whether she is certain of her request should be asked. past obstetric history including mode of deliveries and any abdominal surgeries should be asked.
b) I will tell her that laparoscopy is making a small incision in the umbilicus through which a telescopic camera is inserted and sterilisation is done by applying filschie clip one each to fallopian tube. Laparoscopy is associated with serious and frequent risks. Frequent risks include wound infection, bruising, shoulder tip pain. Serious risks include damage to bladder, bowel, major blood vessels. There is also risk of port hernia. Sterilisation is irreversible, failure rate of 1 in 200, higher risk of ectopic pregnancy if fails, regret. Information leaflets should be given to the woman and clear documentation about the counselling should be done in the notes.
c) Correct technique prevents the risk of visceral and vessel injury. Intraumbilical vertical insertion should be made as this is the thinnest part in the abdominal wall. Verres needle should ideally be disposable and spring action should be checked. It should be inserted perpendicular to the skin and inserted till double clicks are heard(rectus sheath and peritoneum). Further pushing in of verres needle should be avoided as this increases the risk of visceral injury and lateral movements avoided as it can convert a simple stab into a complex tear. Intraabdominal pressure is increased to 20-25 mm Hg as this provides good splinting and avoids visceral injury during insertion of trocars. Primary trocar should be inserted perpendicular to the skin and once in the peritoneal cavity should be directed towards the pelvis. Secondary trocars should be inserted under direct vision and only then intraabdominal pressure reduced to 15 mm hg to facilitate adequate ventilation by anaesthetist. All secondary ports should be removed under direct vision. If there is previous midline laparotomy, then alternative entry sites such as open (hasson) technique, palmer\'s point ( 2 cm below the 9 th rib in the mid-clavicular line) should be employed to prevent visceral injury. The risk is further reduced if the operation is performed by an experienced operator and with adequately maintained instruments.
Posted by Priti T.
prt

a]This patient requesting sterilisation is already overweight,BMI more than 25kg/m2.She should be asked the detail obstetric history regarding the CS/normal delivery and any associated complications.Hx Of any abdominal operations,peritonitis or inflammatory bowel disease is to be asked as they increase the risk of adhesions.She should be asked that she is in stable relationship or intends to change partner which may be a cause of regret in future.History of LMP and the contraceptive use should be elicited.

b]Patient should be informed thatLaproscopic sterilisation is a irreversible process and NHS does not pay for the reversal or IVF ,in case she wants a child in future.She should be given information about the LARC[long acting reversible contraceptives]orLNG-IUS before taking consent for the sterilisation.
The failure rate of Laproscopic sterilisation which is1:200 should mentioned to the patient and she should be advised to use contraceptive till the next period.Alternatively she can be advised that vasectomy is a simpler and more effective procedure having failure rate of 1:2000 and done in local anasthesia.
She should be told that Laproscopic sterilisation is a day procedure done in general anasthesia.Its a key hole surgery with rapid recovery.Various complications encountered in surgery should also be explained to her like bowel injury ,0.4/1000 which is not very frequent.The risk of major vessel injury which is 0.2/1000.Written information and the leaflets are to be given .In an event of complication ,it should be made clear to her that opertion may be completed by Lapratomy and consent taken before hand.Late complications like hernia formation with the entry ports should be mentioned.

c]To decrease the intraoperative risk of visceral and vessel injury,patient should be assessed preoperatively by anasthetist for the various risk factors mentioned above.Laproscopic surgeon should be properly trained and the equipment should be in excellent order with trained assistants.
Patient is asked to empty bladder or cathetarised before surgery to avoid the injury to bladder.Prophylactic antibiotics are given to avoid the flare up of pelvic infection.Abdomen and pelvis are checked for any pelvic mass and the position of aorta,before the insertion of Verres needle for the creation of pneumoperitoneum of 20-25mmof Hg .Extensive lateral movement of the needle is avoided as it may convert small needle point injury of bowel/vessel into a more complex tear.After the two failed attempts at the entry either open Hassan\'s technique or Palmer point of entry[3cm below the costal margin in left mid clavicular line] shoul be used.These 2 ports are especially useful if the patient has abdominal midline operation/CS, as the adherent bowel is avoided.
Use of trochar sleeves with a coarse screw profile on its outer aspects locks the cannula and avoids its slippage with subsequent reintroduction which increases the vessel injury.
Once laproscope is introduced through the primary cannula it should be rotated through 360 degree to check for the adherent bowel.Transillumination should visualise inferior epigastric vessel to avoid the damage.If the bowel is adherent at umbilicus,then the primary trochar site is visualised fro the secondary port,preferrably with a 5mm laproscope.Placement ofsecond and other ports under direct laproscopic visualization avoids the injury to deep epigastric vessels which run in medial epigastric fold beneath the lateral margin of rectus sheath.
Should the bowel/vessel injury occur and it is recognised,the trochar is not removed and Lapratomy is performed.Bowel is repaired with the help of general surgeon.
After the application of Filshie clips in the sterilisation procedure,if any bleeding occurs,bipolar cautery should be used.As unipolar cautery is less safe and has more generalised effect.
To avoid the late complications of hernia formation,the number of puncture sites are kept minimum.The rectus sheath is to be closed using a J shaped needle for any incision of 10mm or more.
Posted by Seema  B.
First I will ensure she is sure about her decision for sterilisation and her family is complete.
A) Mode of previous deliveries with time of last delivery is enquired.Previous operative delivery increases the risks of intra abdominal adhesions.
I will ask her the date of last menstrual period and the regularity of cycles to avoid luteal phase sterilisation.
History is taken regarding current and past contraceptive use .
History regarding any previous laparotomy specially for bowel disease or a history of inflammatory bowel disease or peritonitis in past is taken.Associated with adhesions making laparoscopic sterilisation difficult .

B) I will explain her regarding nature of operation that this is a permanent and irreversible method of sterilisation
This is a minimally invasive surgery done as day case .
There are associated complications which are related mainly to entry techniques.Measures will be taken to prevent complications.
She will be explained regarding choice of anaesthesia by an anaesthetist.
Iwill explain her the procedure of tubal occlusion.Filshie clip will be placed 1-2 cm from uterin cornua at right angles encasing the full width of tube to minimise failure rate.
Failure rate of the procedure will be told to her.Depends on surgical expertise and associated risk factors present.
Serious risks like possible bowel and visceral injury and frequent risks like abdominal and shoulder tip pain will be informed to her.
Possibility of incisional site hernia as a late complication will also be told to her.
I will explain her the circumstances when laparotomy will be needed like visceral injury or to complete the procedure through mini laparotomy in case of failure.
She will be told of increased chances of ectopic pregnancy in case of failed sterilisation.
An informed consent will be needed.
I will provide her with written information and give follow up appointment.
Clear documentation of the counselling and patient wishes if any stated will be done in notes.

C) The surgical team should be well trained and experienced.They should be familiar with the instruments which are well tested beforehand.
The operating table should be horizontal at the start
Abdominal examination should be done under anaesthesia to look for any abdominal masses and position of aorta .Bladder should be catheterised to minimise the risk of injury.
The site of primary trocar and cannula insertion should be properly selected.Normally intraumbilical insertion done but if adhesions suspected from previous surgery or peritonitis alternative site like Palmers point should be used
Verres needle can be inserted bi closed or open--Hasson technique.Open laparoscopy does not necessarily avoid injury to adherent bowel.The primary incision should be intraumbilical and vertical--shortest distance to traverse abdominal cavity.
Verres needle should be disposable preferably and inserted at right angles to skin avoiding lateral movements once inside peritoneal cavity to minimise extension of injury if any to viscera or blood vessels.
Appropriate insufflation pressures should be ensured during and after insertion of trocar and cannula so as to maintain safe patient ventilation without compromising surgery.
Second generation endotips and radially expanding trocars are alternatives with reduced trocar site bleeding.
After insertion of laparoscope entire abdominal cavity should be visualised for any adherent bowel and injury to viscera or bowel.
Secondary ports 5 mm should be inserted at right angles to skin and under direct vision and taking care to avoid injuring the inferior epigastric vessels.Following insertion care taken to angulate the tip of trocar towards anterior pelvis to minimise visceral injury .
Avoid diathermy for sterilisation as risk of bowel injury is more.
Secondary ports should be removed under direct vision to identify and treat any haemorrhage or injury.
For any midline port more than 10 mm and non midline port more than 7 mm rectus sheath should be sutured to avoid herniation of any viscera.
Posted by A S.
Dear Dr Paul
I made a mistake about use of contraception for 3 months after sterilisation but it is stated in RCOG evidence -based clinical guideline number 4 that (.Recommendation 28
B Tubal occlusion can be performed at any time during the menstrual cycle, provided that the
clinician is confident that the woman has used effective contraception up to the day of the
operation. If this is not the case, the operation should be deferred until the follicular phase of
a subsequent cycle. The woman should be advised to continue to use effective contraception
until her next menstrual period)
Posted by A S.
In the same guidline
(General evidence for recommendations
21
There are a number of studies which look at ‘regret’, satisfaction and effects of sterilisation,
including helpful data generated by the Collaborative Review of Sterilisation (CREST) study.15 Issues
from these studies provide a basis for a common list of criteria that should be addressed with
patients considering sterilisation:
• young age (under 30years)16–19
• few or no children (the number is not always defined but usually relates to two or fewer)17
• not in a relationship
• not in a mutually faithful relationship or in crisis in relationship 20–23
• psychological issues (implications beyond fertility issues)21
• psychosexual issues24
• coercion by medical professional or partner25,26
• timing relating to abortion or childbirth20,21,24,25
• information requirements (of the procedure, its effectiveness/failure, alternative contraceptive
choices).27

how can we write these information in a way to gain more marks
Posted by Arun J.
a- I would ask her LMP,Regularity of her cycles, date of her last coitus,last child birth ,whether she is using any contraceptive and if so what method and the duration of use and also past history of abdominal surgeries.

b-I would tell her that it is a permanent method of sterilisation and that it is a day case minimal access surgery.She needs anaesthetic review and baseline blood and urine pregnancy test (though negative pregnancy test does not R/O luteal phase pregnancy).I would tell about the procedure(like the different ports,creation of pneumoperitoneum,and occlusion of tubes by filshie clrings and the need for laparotomy if entry fails), the advantages (quick return to work ,less pain and less morbidity),the complications (bowel injury0.4/1000, vascular injury 0.2/1000, lifetime failure rates of 1in 200procedures and also of the risk of ectopic pregnancy if if fails).I would give written information and document it.I would advice her on using additional contraception until the next periods,and if she is already on IUCD i would tell her not to remove it till the next period.

c-Adopting horizontal position rather than trendelenberg position,testing of instruments prior to surgery are safe simple and effective way of minimising visceral damage.Using sharp veeres needle with good spring action and preferablly disposable ones gives good outcome except for the cost.Optical veeres and endotip(second generation) can be considered though they do not significantly prevent visceral damage inspite of the increased cost of the instrument.Alternative entry techniques can be considered like direct trocar entry(though it does not show any safety disadvantage) and open hasson technique (it decreases use of sharp instruments and allows insertion of blunt trocars under direct vision, can be used in obese and thin nullips where risk of visceral damage is more).Palmers point entry is helpful in those with midline abdominal scars as the risk of bowel adherence in umbilical site is 50%, but cant be used those with spleenomegaly and patients with subcostal scars.Gas insufflation pressure kept to 20-25 mmhg to act as a splint but needs to be reduced to 12-15mmhg for operative laproscopy as it also aids in ventilation of the patient by the anaesthetist .Intraabdominal position fo the veeres is confirmed by pressure/ flow method as it is more safe than others like rotating the needle.All Accessory port trocar entry as well as removal needs to done under direct visualisation as it aids in early diagnosis of injury so as to plan early treatment, thereby minimising morbidity.Last but not the least good training ,skill and expertise for doiung these procedures is needed to minimise complications.
Posted by Osman A.
a.Her detail menstrual history should be asked especially her first day of last menstrual history. Her previous and current form of contraception and side effect or failure of contraception should be obtained. Reason for sterilization should be explored and ensure there is no element of coercion from her partner. The number of children and stability of her relationship to her partner is important information. History of previous surgery should be asked. Her understanding about other form of reliable contraception should be asked. Her understanding about different method of sterilization should be explored.
b. She should be informed about natural of procedure, includes insertion of veres needle, insufflation of gas and 3 small incisions on her abdomen. This procedure will require some form of anesthesia (regional or general) and it can be done as day care basis. She should know that this is permanent procedure but the life time of failure rate is 1 in 200. The risk of ectopic pregnancy should be stressed on should she conceive after the procedure. The complication like bowel, bladder and vessel injury should be informed. She should be made to understand that should these injuries occur she may require laparotomy.
c. Palpation of abdomen to look for presence of masses should be done before insertion of veres needle. This surgery should be done by trained surgeon or under proper supervision. The laparoscopic equipment should be checked before starting the procedure. The insufflation of gas should be created until intra-abdominal pressure reaches to 25mmHg before insertion of primary trochar. Palmer’s point or opened method should be used for insertion of primary trocar if the patent has previous midline laparotomy or previous surgery. The patient with extreme weight (either obese or too thin), open method or Hansen method should be used. Second trocar should be inserted under direct vision with telescope. Observation of symptom of sign of visceral injury post operatively should be done. The patient should be taught about alarming sign for visceral injury like abdominal distention and pain with fever.
Posted by Ava L.
a-Past gynaecological history including her last menstrual period, current contraception and compliance is taking as she might be pregnant at time of operation. Past obstetrical and surgical history is taken due to the possibility of presence of intra-abdominal adhesion which can alter surgical approach or entry site of trocar. Past medical history of inflammatory bowel disease, pelvic sepsis or peritonitis is taken also as these condition mught also cause pelvic adhesion and the patient may be not suitable for laparoscopic sterilization.

b- - The patient informed that tubal occlusion is a permanent method of contraception. Failure rate is about one in every 200 cases. Alternative methods are presents like long acting methods LARC eg: intrauterine device ( Mirena), hormonal patch or implants, they can carry additional positive health benefits over tubal occlusion which carries no other benefit apart from contraception. Vasectomy is also a safer and more effective alternative as failure rate is only about one in every 2000 cases. Reversal of tubal occlusion can be done successfully provided that the tubes condition is well and adequate in length, however, it will be associated with increased incidence of tubal pregnancy. I inform her that laparoscopy is a minimal access surgery, it carries the advantage of quick recovery and early return to work. It also associated with les postoperative pain with avoidance of large wounds as it will be done via small insicions about 1-1.5 cm, one below her navel and the other just 2 cm from her bikini line. However, if a difficulty is encountered during operation or complications occur, the operation may be shifted to laparotomy. The possible serious complications that may occur include bowel injury ( 0.4%), urinary tract injury (0.2%) or more rarely vessels injury. Patient information leaflet Is given.

c- Creation of adequate pneumoperitonium can reduce incidence of visceral injury as the abdominal wall will be away from viscera, the abdominal wall is also elevated by hand. Verrus needle and the trocar are inserted in a direction toward the pelvis to reduce risk of injury to major abdominal blood vessels particularly in a thin patients. Keeping the patient in a straight position and avoiding of Trendelens\' burg position will help protecting the vessels also. If we feel the click of entrance to peritoneal cavity, we should avoid further excessive insertion of both verrus needle and the trocar to avoid reaching the bowel. We should avoid also unnecessary lateral movements because if a small injury occurred during insertion, this movement might enlarge the injury. Early suspicion and detection of complications will aid also minimizing the consequent risks, so we push about10-15 cc normal saline with a syringe via Verrus needle then aspirate it, normally an air will come back to the syringe but if blood or bowel content-like fluid appear, this may indicate bowel or visceral injury. Inspection of abdominal cavity is done after insertion of telescope looking for evidence of bowel content or evidence of injury. The secondary trocar should be inserted under direct vision to avoid injuring abdominal wall blood vessels or abnormally adherent viscera. If the patient had previous operations or adhesion suspected, the primary trocar can be inserted by open method [ Hassons\' Method], or entrance via palmer point which is located 2 cm below costal ridge on left mid clavicular line. If the patient become heamodynamicly unstable during operation, vessels injury should be excluded as bleeding may pass unnoticed to the retroperitoneal space. Meticulous surgical techniques with carefulness in using electrical cauterization can help also reducing incidence of injury. If difficulty is encountered during the procedure or the patient have excessive pelvic adhesions, we can progress to laparotomy to avoid complications provided that the patient is fully informed about that option preoperatively. If a visceral injury occurs or suspected, we should call for help of relevant colloquies like bowel surgeon, surgical urologist or vascular surgeon. Small visceral injury can be repaired via laparoscopy while large or difficult injuries will require laparotomy.
After removal of trocars, the abdomen is deflated, if the smell of the air coming out is similar to the smell of bowel content, a consideration should be taken to re-check the patient as she may got unnoticed bowel injury.

Posted by A S.
Thank you for clarification
Posted by Mark D.
the 3rd part says \" evaluate\" . we haqe just outlines the measures acc to evidence. arent we expected to write advts and disadvts of various intraoperative measures.
Posted by Mark D.
dear sir,
The 3rd part says \" evaluate\" . we have just outlined the measures according to evidence. Are\'nt we expected to write advts and disadvts of various intraoperative measures?
Posted by Maayka ..
(Trini)

a) History about choice for laparoscopic sterilisation and reason why this was chosen may revel that patient may be unaware of the other options fully. Asking if all 5 children are okay and whether she had a vaginal or abdominal delivery will ensure that she has completed her family. Is she in a stable relationship? – this should reduce the chance of regret. Have there been other surgical operations done in the abdomen or pelvis and if so, what type of incision was made. Were there any anaesthetic complications. Her LMP and use of contraception will ensure that measures are taken to avoid the possibility of the procedure being done in an early pregnancy.

b) I will inform her that it is irreversible under the NHS scheme and there is a risk of failure 1 in 200, with a risk of ectopic pregnancy if a pregnancy does occur. There are also risks of injury to the bowel, bladder and blood vessels. The advantages of the procedure is that it is a short procedure in trained hands and can be done as a same day case. Minimal analgesics should be required and there will be a quick recovery time with early return to work /other activities. Providing contraception is used till the time of the procedure, it offers immediate sterilization. She should be told of the option of vasectomy for her male partner and other options to ensure she made the best informed choice. She should also be told of the risk of laparotomy should injury occur.

c) It is important to have palpated the abdomen before starting, to ensure no masses are present which will hinder visualisation. If the are surgical scars, it is best to choose the point with least likely adhesions under the abdominal anterior wall. If there are no scars the base of the umbilicus is the thinnest part chosen for entry of the Verres needle. If there is a midline incision, the Palmer’s point can be used to check under the umbilicus to ensure no adhesions or to dissect off adhesions before the Verres is inserted. The abdominal entry should be done at 90 degrees after insufflation to 20-25mmHg of intraabdomianl pressure – this ensures the distance from the skin to the peritoneum is increased and reduces the chance of injury to major blood vesssels.
Once the trocar is inside the area around the entry site should be inspected with the camera to ensure no bowel has been entered or bleeding vessels. If additional ports required, it should be inserted under direct vision with the scope to avoid blood vessels like the inferior epigastric artery. Removal of all ports should be done under direct vision to ensure no bowel injured during the exit or blood vessels actively bleeding. A uterine cannula is used to move the uterus, antevert or retrovert to assist the surgeon in visualizing as well as to move the tubes away from bowel before the clips are applied.
The diathermy use should be done with caution. When applying the clips it is necessary to ensure that the fimbrial ends are seen to prove it is tube and also checking anteriorly and posteriorly to ensure bowel not clamped.

Posted by Atashi S.
(A) Menstrual history including LMP is important as it is preferable to do sterilisation in the follicular phase of the cycle. Gynaecological history should be noted carefully including presence of menorrhagia or secondary dysmenorrhoea which may need alternate or additional procedure. Contraceptive history should be noted including use of IUCD, mirena or use of any depot preparation. Past obstetric history including mode of delivery( caesarean section or normal vaginal delivery ), any history of puperal sepsis is to be taken .
(B) I will tell her It is a permanent method of contraception it will lead to complete lost of fertility. Long term contraception like IUCD , inject able depot preparation, norplant should be discuss with her. It will be done as a day case procedure. In this procedure tubal occlution is done mostly by using failshi clip or huka clip .The procedure associated with life time failure rate of 1 in 200. I will tell her about vasectomy which is associated with lower failure rate(1 in 2000). It will be done under general anaesthesia which is associated with some inherent risk. It is reported that about 33% death due to sterilization is associated with anaesthetic complication. Laparoscopy associated with inherent risk of blood vessel injury, bowl injury and injury to major vital organ. Sometime there may be difficulty arises during entry to abdominal cavity and laparoscopic sterilization could not be possible, then Laparatomy may be needed. I will provide her written and documented information.
( c ) To minimise the risk of visceral and vuscular injury during laparoscopy it should be kept always in mind that the procedure is associated with inherent risk .Procedure can be done by adequately trained surgeons under appropriate supervision.Examination under anaesthesia is to be done to exclude any abdominal mass .Bladder catheterisation is to be done to evacuate bladder. Use of appropriate and well maintained instrument. Appropriate entry technique is important, the direction of insertion, use of guarded point instrument and insertion of secondary port under direct vision. Women with previous abdominal surgery vering the point of entry of primary port (palmers point) may prevent visceral injury. Open laparoscopy will not necessasarily avoid injury to adherent bowl. Use of bipolar diathermy is preferable to unipolar diathermy.