Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis Salpingoophorectomy And Oophoropexy of Torsion Of Ovary
Gynecology / Dec 23rd, 2019 3:45 pm     A+ | a-
Dr. Indra Gazali Syamsuddin
Specialist Obstetrician Gynaecologist. F.MAS. D.MAS. F.ART. FICRS. INDONESIA
 
INTRODUCTION
 
Ovarian torsion is the twisting of the ovary on its vascular support is the fifth most common gynecologic surgical emergency.1 The condition is more common in premenarcheal females (children or premenarcheal adolescents) constitute up to 15–50 % of adnexal torsion cases.2 The association of an ovarian cyst is a common finding in twisted ovaries, the size of the cyst is usually moderate (i.e. around 5 cm).3.4.5.6  Diagnosis is basically clinical, however, pelvic imaging, primarily by transvaginal ultrasound (TVUS) and Doppler evaluation of ovarian blood flow, confirms the diagnosis and excludes similar conditions.7,8
The gold standard to treat ovary torsion is surgery (laparoscopy and laparotomy.9 An ovarian cystectomy is often performed for a benign ovarian mass. If malignancy is highly suspected, a salpingo-oophorectomy is needed. According to many observational studies, detorsion is associated with preserved ovarian function. 10,11,12,13 
The risk of recurrence after detorsion, but the incidence and causes are unknown. 14,15,16,17 One method is suppression of ovarian cysts by oral contraceptives.18,19 Another method is an oophoropexy by plication of uteroovarian ligament 20,21
 
PRE-OPERATIVE PREPARATION:
 
1. Patient to be under General anesthetized
2. Patient return plate should be attached to the thigh.
3. Abdomen and perineum to be painted and draped
4. The surgeon has to be on the patient’s left side, an assistant on the right side and 2nd assistant if needed in between patients legs for uterine manipulation
5. Monitor to be placed 15 degrees below the visual axis of the surgeon on the opposite side. 
6. All the equipment placed on the opposite side of the surgeon
7. Camera, light source, insufflator, and electrosurgical unit to be plugged into their respective equipment and all cables tied over upper drape using a gauze and towel clip.
8. Telescope with a camera attached to the light source.
9. Laparoscopic mode to be “on “on the camera cable attachment instrument
10. White balancing and focussing of camera done by placing the camera at a focal length of 10cm from gauze piece.

OPERATIVE STEPS PROPER:

PNEUMOPERITONEUM
1. Over inferior crease of the umbilicus, place 2 Allis tissue holding forceps on either side and give 2mm stab incision with No.11 blade.
2. Dilate rectus muscle until rectus sheath with mosquito forceps 
3. Check Veress Needle of 12 cm for its spring action and patency
4. Lift up the abdominal wall at the umbilicus and assess its full thickness,
5. Veress Needle is held like a dart the thickness of the abdominal wall from its distal end.
6. Insertion of veress needle through the incision site in a manner that the veress needle makes an angle of 90’ with the abdominal wall and an angle of 45’ with the body of the patient, pointing towards the anus.
7. Insertion is achieved with two audible clicks; first of the Rectus Sheath and second of the
Peritoneum
8. Release the Allis forceps from the Abdominal wall
9. Hold the Veress Needle at an angle of 45’ making sure that no further length of the needle is advanced.
10. Confirm the intraperitoneal placement of the veress needle by aspiration test, irrigation test and hanging drop test.
11. Ensure that the Gas tubing is attached to the Insufflator and the Insufflator is switched ON. This will remove air from the Gas tubing and fill the gas tubing till its tip with CO2 gas.
12. Confirm Pre-Set Pressure to 15mmHg on the Insufflator and Attach the gas tubing to the veress needle and start the flow of CO2 gas at 1 liter per minute
13. Confirm obliteration of liver dullness and generalized distension of abdominal wall
14. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation.
15. The total amount of gas and actual pressure should rise in a linear fashion.
16. When actual pressure has reached pre-set pressure and amount of gas used might vary between 1.5 to 6 liters for an averagely build young patient
17. Once the pressure reaches the pre-set pressure, remove the veress needle and use size 11 blade to make skin incision to fit a 10mm port. This can be prechecked by placing a 10mm port on the skin for estimation of incision size
 
PORT PLACEMENT
 
1. Insert the 10mm cannula with trocar by oscillatory screwing motion, the direction being
perpendicular till give way sensation is perceived and then change the direction towards the pelvis. Once you are in, the trocar should be removed and the telescope should be inserted to confirm the intraperitoneal placement
2. Connect the insufflator to the optical port and switch on the gas.
3. To begin with, an overview inspection of the entire abdomen must be done and noted.
4. Then reach out to the target organ (ovary of affected side), just about to touch it with the tip of the telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.
5. Use the baseball diamond concept to mark the position of the additional 5 mm ports.
6. Make 15 to 30 degree Trendelenburg tilt aids in moving the bowel to the upper abdomen.
7. The surgeon must use transillumination to avoid any vessel injuries in prospective port sites. Use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
8. Based on the baseball diamond concept, 2 ipsilateral 5mm secondary ports made. 1stport is 7.5cm from primary port and 2ndport, 7.5cm from 1stport along the 18 cm arc.
9. Insert both the 5mm ports under direct vision and using principles same as that used for the primary port to avoid inadvertent visceral and vascular injuries.
10. These ports have to be placed such that the manipulation angle is 60degrees, elevation angle is 30 degrees and azimuth angle from 30 degrees to a maximum of 60 degrees as they are ipsilateral ports
 
 
SURGICAL STEPS:
 
SALPINGOOOPHORECTOMY
 
1. The uterine manipulator can be used to lift up the uterus for proper visualization.
2. Grasp the ovary which has undergone torsion with an atraumatic grasper and with tritome puncture the cyst and aspire the contents.
3. Undo the torsion with the help of 2 graspers and wait for 3-5 minutes for the blood supply to return.
4. If the ovarian tissue has become gangrenous and has to be removed and so proceed with salpingooopharectomy with coagulate and cut infundibulo pelvicum ligament
5. Coagulate and cut ovarian ligament mesovarium, fallopian tube
6. Coagulate and cut mesosalpinx 3cm lateral to the uterus
 
OOPHOROPEXY
 
1. Oophoropexy  by suturing continues  and tightening the proximal to the distal end of the ovarii proprium ligament to prevent further torsion in the future
2. Take it out the cyst with endobag / take it out to the posterior fornix posterior wall vaginal with colpotomy 
3. Clean the peritoneal cavity with suction irrigation.
4. Keep watch on ETCO2 level during surgery
5. Deflate the abdomen, remove the ancillary port under the vision and the primary port removed along with trocar.
6. Close 10mm port with veress needle or port closure after desuffation
7. Extubate patient and shift patient to recovery room
 
REFERENCE:
 
1. Balci O, Icen MS, Mahmoud AS, Capar M, Colakoglu MC (2010) Management and outcomes of adnexal torsion: a 5-year experience. Arch Gynecol Obstet 284(3):643–646. doi: 10.1007/s00404-010-1702-zPubMedCrossRefGoogle Scholar
2. Pansky M, Abargil A, Dreazen E, Golan A, Bukovsky I, Herman A (2000) Conservative management of adnexal torsion in premenarchal girls. J Am Assoc Gynecol Laparosc 7(1):121–124PubMedCrossRefGoogle Scholar
3. D.W. Swenson, A.P. Lourenco, F.L. Beaudoin, D.J. Grand, A.G. Killelea, A.J. McGregorOvarian torsion: case–control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department Eur J Radiol, 83 (4) (2014), pp. 733-738
4. Varras M, Tsikini A, Polyzos D, Samara CH, Hadjopoulos G, Akrivis CH, et al. Uterine adnexal torsion: Pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol 2004;31:34-8.  
5. Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol 2007;109:355-9
6. Houry D, Abbott JT. Ovarian torsion: A fifteen-year review. Ann Emerg Med 2001;38:156-9.
7. Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstetrics & Gynecology. 2007;109(2, Part 1):355–9.
8. C. Huchon, A. FauconnierAdnexal torsion: a literature review Eur J Obstetr Gynecol Reprod Biol, 150 (1) (2010), pp. 8-12
9. Hubner N, Langer JC, Kives S, Allen LM. Evolution in the management of pediatric and adolescent ovarian torsion as a result of quality improvement measures. J Pediatr Adolesc Gynecol 2017;30:132-37.
10. Arkins G. Ovarian torsion treated with untwisting: Second look 36 hours after untwisting. J Minim Invasive Gynecol 2007;14:270.
11. Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990;53:76-80
12. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z, et al. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173:363-6.
13. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 1993;60:976-9
14. Germain M, Rarick T, Robins E. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996;88:715-7.
15. Crouch NS, Gyampoh B, Cutner AS, Creighton SM. Ovarian torsion: To pex or not to pex? Case report and review of the literature. J Pediatr Adolesc Gynecol 2003;16:381-4.
16. Ozcan C, Celik A, Ozok G, Erdener A, Balik E. Adnexal torsion in children may have a catastrophic sequel: Asynchronous bilateral torsion. J Pediatr Surg 2002;37:1617-20
17. Grunewald B, Keating J, Brown S. Asynchronous ovarian torsion – The case for prophylactic oophoropexy. Postgrad Med J 1993;69:318-9.
18. Functional ovarian cysts and oral contraceptives. negative association confirmed surgically. A cooperative study. JAMA 1974;228:68-9.
19. Grimes DA, Godwin AJ, Rubin A, Smith JA, Lacarra M. Ovulation and follicular development associated with three low-dose oral contraceptives: A randomized controlled trial. Obstet Gynecol 1994;83:29-34
20. Kaleli B, Aktan E, Gezer S, Kirkali G. Reperfusion injury after detorsion of unilateral ovarian torsion in rabbits. Eur J Obstet Gynecol Reprod Biol 2003;110:99-101
21. Fuchs N, Smorgick N, Tovbin Y, Ben Ami I, Maymon R, Halperin R, Pansky M. Oophoropexy to prevent adnexal torsion: how, when and for whom? J Minim Invasive Gynecol 2010;17:205–8.
2 COMMENTS
Dr. Madhu
#1
May 21st, 2020 2:40 am
The topics were very interesting, I feel I learned so much. Thanks for sharing your knowledge of Task Analysis Salpingoophorectomy And Oophoropexy of Torsion of Ovary.
Dr. Srikant Rai
#2
May 22nd, 2020 4:38 am
Impressive and very interesting of each technique was very well presented topic. Thanks for sharing your knowledge of Task Analysis Salpingoophorectomy And Oophoropexy of Torsion of Ovary.
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