Task Analysis of Laparoscopic Procedures

Task analysis of Laparoscopic salpingostomy for unraptured Ectopic Pregnancy
Gynecology / Feb 23rd, 2017 6:51 am     A+ | a-
Dr. Bushra  AL Johani
MBBS, SBOG,MD
KSA. AL Madinah 


Definition:-

Ectopic pregnancy defined as implantation  of pregnancy outside the uterine cavity
 



Risk Factor for Ectopic Pregnancy
  • Previous PID – chlamydia infection
  • Previous ectopic pregnancy
  • Tubal ligation
  • Previous tubal surgery
  • Intrauterine device
  • Prolonged infertility
  • Diethylstilbestrol (DES) exposure in-utero
  • Multiple sexual partners
Mangment of ectopic pregnancy:

1. Conservative 
2. Medical treatment by methotrexate   
3. Surgical management by Laparoscopy or laparotomy if patient unstable.
 
Preoperative preparations:

1. Blood investigations and Pre-anesthetic check up
2. X-match
3. Informed consent
4. Preop.antibiotics.
‚Äč5. Surgical team: Surgeon, Anesthetist, Assistant, Scrub nurse

Equipment and Laparoscopy Tower:

1. Monitor (Desirable 26” HD
2. Light Source and Camera Control Unit (Desirable – LED light source and 3 Chip HD Camera)
3. Insufflator and CO2 Gas Cylinder 
4. Electro Surgical Unit (Desirable – High Frequency Generator)
5. Select Pre-set Pressure (Ideal 12 to 15mmHg)
6. Video Recorder & Printer
7. Suction Irrigation system
8. Veress' needle – 12 cm length
9. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports

laparoscopic set :

. Maryland.
. Laparoscopy Aspiration Needle 
. Laparoscopic scissors
. A traumatic grasping forceps
. Tissue Dissection forceps
. artery forceps
. Suction Irrigation tubing
. Set of Allis forceps
. Surgical Blade No 11 
. Syringe and Normal Saline (10ml)
. No 20 G “spinal Needle or laparoscopic needle.
. Vasopressin 5 unit diluted in 20 ml of saline.
. Monopolar hook.
. Sterile dressing 3

Position of patient:

. Supine position in Trendelenburg position.

Position of the surgical team and equipment:

1. Surgeon on the left, distance from the screen is 5 times diagonal length of the screen which is placed opposite and in front of the surgeon.
2. Assistant on the right of the surgeon.
3. Scrub nurse on the left of the surgeon.
4. Anesthetist in the usual position on the head end.

Procedure:

Site – Inferior Crease of Umbilicus
1. Hold umbilicus with Allis forceps on either side to Evert the inferior crease of umbilicus
2. Make a stab incision of 2mm with No 11 surgical blade
3. Check Veress Needle for spring action and patency
4. Lift up the abdominal wall area below the umbilicus and assess its full thickness
5. Veress Needle is held like a dart at a level of 4 plus thickness of abdominal wall in centimetres by its shaft.
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 patient
7. Veress Needle insertion is aimed at the anus
8. Insertion is achieved with two audible clicks; 1st of the Rectus Sheath and 2nd  of the Peritoneum
9. Release the Allis forceps and Abdominal wall
10. Hold the Veress Needle at an angle of 45’ making sure that no further length of needle is advanced
11. Placement of Veress Needle inside peritoneal cavity confirmed by attachment of a 10ml Syringe filled with
12. Normal Saline and performing following tests:
a. Irrigation Test: Injecting 5ml of Normal saline, free flow confirms placement inside the peritoneal cavity
b. Aspiration Test: There should not be any returning fluid, confirms placement inside the peritoneal cavity
c. Hanging Drop Test: Drop of Normal Saline is placed at the hub of the Veress Needle and abdominal wall is lifted. Suction of this drop into the abdominal cavity confirms placement inside the peritoneal cavity
d. Plunger Test: Removing the plunger of the attached syringe; free flow of remaining Normal Saline in to the abdominal cavity confirms placement inside the peritoneal cavity.
13. 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.
14. Confirm Pre-Set Pressure to 15mmHg on the Insufflator
15. Attach the gas tubing to the veress needle and start the flow of CO2gas at 1 liter per minute
16. Confirm obliteration of liver dullness and generalised distension of abdominal wall
17. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation
18. The total amount of gas and actual pressure should rise parallel to each other
19. When actual pressure has reached pre-set pressure and amount of gas used is 1.5 to 6 litres for an averagely build young patient
20. Once pressure reaches the pre-set pressure,  remove the veress needle and use size 11 blade to make a smiling skin incision on the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port on the skin for estimation of incision size. Using an artery forceps the tip should be inserted in this incision and then tip opened to successively dilate the urachus as per the Scandinavian technique of primary port placement.
21. Insert the 10mm cannula with trocar by oscillatory screwing motion, direction being perpendicular till give way sensation is perceived and then change the direction towards the pelvis. Once in, the trocar removed and telescope inserted and confirm the intraperitoneal placement 
22. Then insufflator should be connected to it and gas switched on.
23. To begin with an overview inspection of the entire abdomen must be done and noted. 
24. Then reach out to the target organ (fallopian tube of affected side), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target. 
25. Use the baseball diamond concept to mark the position of the additional 5 mm ports.
26. Surgeon must use transillumination to avoid any vessel injuries in prospective port sites, after which use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
27. Insert both the 5mm ports under direct vision and using principles same as that used for primary port to  avoid inadvertent visceral and vascular injuries.

 Identification of fallopian tube with ectopic pregnancy in situ:

1. find the affected side fallopian tube by using atraumatic grasper and a maryland as probes only. The contralateral tube must also be inspected to determine healthy or not. 
2. The affected tube is identified and mobilized to minimize bleeding, 5to8 ml diluted solution  containing 5 unit vasopressin in 20 ml of normal saline is injected with a 20 gauge spinal or laparoscopic needle , it should be injected in the mesosalpinx  just below the ectopic and over the antemesentric surface of the tubal segment containing gestational product.
3. After stabilizing the tube by grasper in one hand and microelectrode in other ,a linear incision is made on the antimesenteric surface  extending  one tow centimeter over the thinnest portion of the tube .
4. The fine needle tip should be used in the cutting mode , and should barely touch the tissue surface.
5. It is  important to remain aware of the location of underlying or adjacent strucures..
6. The product usually should protrude through the incision and slowly slips out of the tube , it may be teased gently out using hydro dissection  or laparoscopic atraumatic forceps .
7. As pregnancy is pulled out or extruded from the tube and can be placed in a plastic or endobag and removed  through 10mm port on the umbilicus, under vision with the 5mm telescope in the lateral port..
8. After the pregnancy  is removed the area operated upon must be visualized for perfect hemostasis.
9. The 10mm umbilical port fascia must be closed using a veress needle as a suture passer(Suture used  is vicryl 0.0).Before tying the suture the port is to be removed together with the telescope and all gas let out.
10. Precaution while removing Primary port - Do not abruptly remove the port. 
11. Keep the telescope in the abdominal cavity and start withdrawing the cannula 
12. Continue to observe this withdrawal process on the monitor
13. Once the cannula has reach within the abdominal wall then start withdrawing the telescope
14. Remove the cannula and the Telescope under vision. 
15. This process will avoid entrapment of Omentum or Bowel within the Primary port wound
16. Primary Port fascia and Skin closed; Secondary Port Skin closed
17. Skin closed  with fine Monofilament suture
18. Abdomen cleaned and Port site wound dressing applied
19. Patient monitored till comes out of general anesthesia and post op vitals and operative findings must be duly noted in patient case sheet.

Tissue retrieved must be sent for histopathological examination and patient once stable must be shifted to post op care area for further management.

Provide Surgery Photos or Surgical Video to the patient.

Provide Discharge Summary documenting Insitu findings of the surgery .

 
1 COMMENTS
Dr. Rahul Kumar
#1
Feb 26th, 2017 12:41 am
Nicely written about Task Analysis of Laparoscopic salpingostomy for unraptured Ectopic Pregnancy.thanks Dr. Bushra AL Johani
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