Task Analysis Laparoscopic Bilateral Tubal Ligation By Falope Ring Application
Task Analysis Laparoscopic Bilateral Tubal Ligation By Falope Ring ApplicationDR. RAJANI. C. MS(OBG), DNB(OBG), FMAS
Equipment needed :
• Laparoscopic drapes, insufflators, Light source, HD camera with 30-degree telescope (10mm), seven parameter monitor, LCD monitor
• Veress needle 12 cm with 10 ml N/S syringe, and 10 ml xylocaine 2% for subcutaneous injection before doing skin incision.
• One 10 mm port and one 5 mm port
• 11 number scalpel
• Fallope ring applicator and the rings should be ready with the ring pusher. The rings should be loaded in the ring pusher not more than 10 minute before the application.
• Procedure can be performed under GA or LA
• Put the patient in supine position with 15-degrees head down.
• Quadrimanometric device ready, the preset pressure should not be more than 12 mm and the gas flow rate is 1L/min.
• Position of the surgical team: Surgeon on the left side of the patient and in coaxial alignment with the target organ (the tubes)and the monitor at a distant about 5*diameter of the monitor & the table height 0.49*surgeon height.
• Disinfect the abdomen from the nipple till the pubic symphysis line and to the level of anterior iliac spines laterally.
• Xylocaine 10 ml is subcutaneously infiltrated around the umbilicus
• By the use of 11 mm blade, 2 mm incision at the lower umbilical skin crease
• Verres needle is checked for valve action and patency by n/s irrigation.
• Hold it like a dart and skin thickness is elicited by holding it at the level of umbilicus and add to it 4 cm for needle tenting, needle should be perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal to make it 45 degree toward patient body.
• Two clicks are heard at this time, during the rectus & peritoneum entry, then check by suction-irrigation test, hanging drop test.
• The insufflator is switched on and connected to the veress needle
• Check the flow rate and the actual pressure at this time, the flow rate not more than 1.5 L/min, the actual pressure increasing gradually, and not exceeding preset pressure.
• When the actual pressure becomes equal to the preset pressure, take out the needle, and do 10 mm smiling incision in the lower umbilical crease.
• Insert artery holding forceps to the incision to dilate the vitellointestinal duct and separate the recti muscles. (Scandanavian technique)
• Insert 10 mm umbilical port and connect the insufflator and close the valve for continuous pneumoperitoneum.
• Insert the10 mm 30-degree telescope and take a panoramic view
• 5 mm port is inserted under direct vision in the left iliac fossa 7.5 cm lateral to the umbilicus according to Baseball diamond theory.
• The fallope ring applicator is inserted through the 5 mm port under the vision of the telescope.
• Going behind the uterus, lift the tubes up
• Open the jaws of the applicator at the isthmus part of the tube 2 cm lateral to the uterus by pushing the handle
• After holding the fallopian tube with the tenaculum, verify the absence of bowel or mesosalpinx and pull the tenaculum along with the tube to make 2 cm loop
• Apply the ring for 5 seconds then release and check ring placement.
• The same is repeated on the other tube. Remove the applicator.
• Take a 5 mm telescope after white balancing and fixation before insertion through the 5mm port.
• Prepare the veress needle and make a loop of thread (proline)to use it for the closure of the 10 mm port to prevent future hernia.
• Close the umbilical 10 mm port under direct vision by no.1 vicryl.
• Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port
• Put a surgical dressing on the port sites.
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