Task Analysis of Laparoscopic Procedures

Task Analysis of Laparoscopic Myomectomy
Gynecology / Aug 25th, 2017 11:31 am     A+ | a-
Dr. Bevunapalli Sirisha,
M.S, OBGY, CAS SPECIALIST AREA HOSPITAL AMALAPURAM
CONSULTANT GYNAECOLOGIST  TRINITY HOSPITALS AMLAPURAM, ANDHRAPRADESH.

DEFINITION: Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus.

SIGNS AND SYMPTOMS:

Symptomatic in only 35-50% of Patients and depend on location, size, secondary changes  & pregnancy status

1-Abnormal uterine bleeding.
2-Dysmenorrhoea.
3-Pressure Effect: occur If large in size that may distort or obstruct other organs like ureters, bladder or rectum urinary symptoms, hydroureter, constipation, pelvic venous congestion & lower linb edema. Rarely  a posterior fundal tumor extreme retroflexion of the uterus distorting the bladder base and urinary retention Parasitic tumor may cause bowel obstruction.
5-Cervical tumors with serosanguineous vaginal discharge, bleeding, dyspareunia or infertility.
6-Infertility: The relationship is uncertain however, 27-40% of women with multiple fibroids are infertile, Endometrial cavitary tumors affect fertility more.
7- Spontaneous Abortion: More with intracavitary tumorsIts  incidence before myomectomy is 40% and after myomectomy is 20%.

IMAGING:
  1. Pelvic U/S with dopplar study is very helpful in confirming
  2. Saline hysterosonography can identify submucous myoma that may be missed on U/S
  3. HSG  will show intrauterine leiomyoma
  4. MRI  highly accurate in delineating  the size, location & no. of myomas
  5. IVP  will show ureteral dilatation or deviation & urinary anomalies
  6. Hysteroscopy  for identification & removal of submucous myomas
CLASSIFICATION
 
Classification of Myoma
 
Laparoscopic management of fibroid uterus:
  1. Selection of patient:should be fit for surgery and general anesthesia.
  2. Only to be done for myomas not exeeding 10cms in size
  3. The number, length, depth, width,location, their type, distance between the myoma and endometrial cavity should be measured on u/s
  4. Dopplar examination gives us the vascularity of the myoma
  5. Operative hysteroscopy should ideally avoided with this procedure as it can provoke distension of uterus that can lead to excessive bleeding during myomectomy
Pre operative preparation of patient:

Consent for myomectomy
Consent for conversion of procedure into open surgery in case of any complication
Consent for chances of hysterectomy in case of severe complications
Bowel preparation: Allowed soft diet till afternoon and followed by liquid diet on previous day of surgery up to 8pm. Nill by mouth at least for 8hrs before surgery. PEGLEC powder can be given for bowel preparation on before night of surgery.preop medication and antibiotic dose to be given 1hr before surgery.

Laparoscopic myomectomy
  1. Anesthesia is general 
  2. Naso-gastric  tube administration
  3. Position of patient: low modified lithotomy, patient lies with Tighes spread, with abduction, and buttocks protruding generously over the edge of the table, that to be combined with 30degree trendlenburgh position after placing the primary port
  4. Patient return plate should be attached to pt buttocks
Instruments and equipment required:

Monitor  CCD-camera, light source, insufflator with CO2 cylinder, electrosurgical generator, suction irrigation system -all in one cart
10mm port, 5mm ports x3, veress needle,10mm 30 degree telescope, Maryland, atromatic-grasper, semi-tromatic grasper, monopolar hook, bipolar grasper, harmonic scalpel, cold scissors, 5mm myoma screw, 2 needle holder, 10mm tenaculum, motorized morcellator, suture material no1 vicrly, knot pushers and suction cannula and tubings, vasopressin 5ml in 100ml NS
 
Position of surgical team:

Surgeon and scrub nurse on left side of pt, monitor target organ and surgeons visual axis in coaxial line, assistant surgeon on right side .we can have another srubbed assistant between the pt legs if we want any uterine manipulation. Preparation of parts done by scrubbing and draping under aseptic techniques.

Preparation of equipment:

Insufflator  is turned on to remove air from tubings and set pressure is set at 20mmhg, set flow rate set at 1 l/min, camera is turned on focusing to be done at 10cms, white balance to be adjusted. Set up the connections of req instrument bipolar/harmonic with electrosurgical generator.
 
Operative Steps proper:
  1. Take veress needle and check for its spring action and patency
  2. Connect the veress needle with CO2 tubing and flush out the dead space
  3. Connect Veress needle to CO2 tubing and flush out dead space
  4. Take 2 Allis forceps to evert and hold each side of umbilicus
  5. Use number 11 blade to place small horizontal stab wound to inferior crease of umbilicus
  6. Mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath 
  7. Measure abdominal wall thickness and add 4cm for distance to hold Veress needle
  8. Hold Veress needle at calculated length like a dart
  9. Assistant and surgeon to hold the lower abdomen up
  10. Surgeon to place Veress needle in sub-umbilical incision at 45 degrees down into pelvis towards anus and also perpendicular to abdominal wall
  11. Insert Veress needle until two clicks felt and Maintain 45 degree angle
  12. Confirm correct Veress needle placement –irrigation test, aspiration test, plunger test, and hanging drop test
  13. Connect CO2 gas tube to Veress needle and  Turn on CO2 and allow flow rate of 1L/min
  14. Observe quadro-manometric indicators to rise in parallel for volume of gas and actual pressure and  Observe for general distension of abdomen and percuss for obliteration of liver dullness
  15. Once pneumoperitoneum is achieved with set pressure of 20 mmHg,extend skin incision horizontally
  16. Hold 10mm port like a gun and insert it perpendicular to abdomen & tilt to 60 degrees towards pelvis when there is loss of resistance
  17. Confirm intra-abdominal placement of primary port with escaping air sound  and audible click and Take out trocar    
  18. Set the pressure rate at 12 mmhg and flow rate at 6 lts/min
  19. Connect  gas tubing to primary port
  20. Insert telescope and inspect entry point
  21. Request for Trendelenburg of 30 degrees position
  22. Camera cable should be at 6 o’clock and light source should be at 12 o’clock
  23.  Apply baseball diamond shape principle for lateral port insertion
  24. If uterus is less than 12 wks size primary port is kept at lower umbilical crease, if uterus is 14 to 18 wks size then primary port will be supraumbellical ,if uterus is 20 wks size primary port should be placed at palmars point
  25. Transilluminate at target organ, the uterus with fibroids
  26. Make a diamond shape with thumbs at umbilicus and index fingers towards target organ
  27. Incise skin along Langer lines for secondary ports x 2
  28. Insert lateral ports (5mm x 2 at LIF and RIF) at position of snuff box which is about 8cm from umbilicussh ould be placed high and outside the epigastric vessels so that good access is provided incase of ipsilateral ports -5mm port in left iliac fossa 3cms above the anterior superior iliac spine, another 5 mm port above and medial to previous port in LIF 5 cms away
  29. All ports should be inserted perpendicular to the abdomen.
  30. Once all lateral ports inserted, then reduce set pressure to 12mmH
  31. Atraumatic graspers to perform systematic inspection of entire abdomen and pelvis in clockwise fashion
Task Analysis After Access
  • Preventive Haemostasis
  • Fixation of Myoma
  • Enucleation Myoma
  • Obliteration of Dead space
  • Retrieval of Myoma
Relation of fibroid with the uterus and fallopian tube should be carefully assessed after inserting the primary port and then secondary ports be decided according to baseball diamond concept.

Preventive haemostasis: 
  • vasopressin 5ml of 1 in 100 dil injected at the junction of the fibroid with the uterus.
  • Now look for blebbing and pallor on fibroid due to vasopressin injected.this acts for 20-30 mins
  • Carefully plan for incision if ipsilateral ports are used then horizontal/oblique incision is recommended in case of contralateral port position vertical or oblique incision is recommended.
  •  In case of multipule fibroids incision is planned in such a way that maximum myomas can be removed from one incision. 
  • Now incise the most bulging part on the fibroid with harmonic scalpel or monopolar hook until the capsule of the myoma is visualized
 
Fixation of myoma and enucleation:
  • With 2 graspers, cut edges are pulled so that the capsule is exposed and myoma screw is inserted
  • Now with myoma screw give gradual traction preferably anteromedial traction and counter traction with blunt instrument like suction cannula and blunt dissection is done
  • Position of myoma screw is changed from time to time to apply traction on cleavage line until enuleation is done
  • The large feeding vessels at the base of the fibroid are cauterized with bipolar and cut with scissors or harmonic scalpel
  • Care is taken not to open the cavity
  • Undue use of cautery is avoided as it leads to defective healing and weak scar formation
  • Myoma after removal is placed in the culde sac or paracolic gutter
Obliteration of dead space
  • Reconstruction of myoma bed is done with no 1 vicryl suture
  • The main aim of suturing is to obliterate the dead space to avoid haematoma formation
  • Extracorporeal knotting technique is preffered
  • Start from one angle first suture should be placed beyond the angle
  • The rest of the defect is closed
  • Last suture should be beyond the other angle
  • The serosal layer is closed with Dundee jamming continuous suturing with Aberdeen termination
Extraction of myoma
  • One of the ports is converted to 12mm and morcellator inserted
  • The myoma is held with tenaculum and is fed to motorized morcellator.
  • Take care not to move morcellator near the tissue instead tissue to be fed to morcellator with tenaculum
  • A meticulous lavage is given, haemostasis is checked and proceeded for port closure
  • Port closure is done under vision with outer sheath of veress needle after slightly deflating the abdomen so that sutures are not in tension
  • The last port to be closed is the telescope port, done after completely deflating the abdomen, and keeping the telescope in and removing the cannula followed by telescope at last.
  • The skin incision is closed with staplers and dressing done.
1 COMMENTS
Dr Dipti Bhatnagar
#1
Aug 25th, 2017 12:28 pm
Nicely written task analysis. Thanks Dr Sirisha
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