Task Analysis of Laparoscopic Procedures

Laparoscopic Management of Torsion Of Ovary
Gynecology / Aug 25th, 2019 10:20 am     A+ | a-

Laparoscopic Management of Torsion Of Ovary 

Dr. Poornima Blagopal
Consultant Gynecologist and Robotic Surgeon

Preoperative preparations:

Ovarian Cystectomy

1. Blood investigations and Pre-Anesthetic check-up
2. Crossmatch
3. Informed consent
4. Preoperative Antibiotics
5. Surgical team: Surgeon, Anesthetist, Assistant, Scrubbed 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. Insufflators 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, two 5mm ancillary ports

Laparoscopic set :


. Maryland.
. Laparoscopy Aspiration Needle, Harmonic
. Laparoscopic scissors
. Atraumatic grasping forceps
. Tritome
. Suction Irrigation 5 mm
. Syringe and Normal Saline.

Position of the surgical team and equipment:


1. The surgeon should stand on the left side of the patient and the 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:


1.Optical port site- supraumbilical (3-4 cms above the umbilicus)
2. Make a stab incision of 2mm with No. 11 surgical blade
3. Check Veress Needle 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 at a distance of 4 cm plus 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.
8. Insertion is achieved with two audible clicks; first of the Rectus Sheath and second of the
Peritoneum
9. Release the Allis forceps from the Abdominal wall
10. Hold the Veress Needle at an angle of 45’ making sure that no further length of the needle is
advanced.
11. Confirm the intraperitoneal placement of the veress needle by ASPIRATION TEST,
IRRIGATION TEST and HANGING DROP TEST
12. 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.
13. Confirm Pre-Set Pressure to 15mmHg on the Insufflator
14. Attach the gas tubing to the veress needle and start the flow of CO2gas at 1 liter per minute
15. Confirm obliteration of liver dullness and generalized distension of abdominal wall
16. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation
18. The total amount of gas and actual pressure should rise in a linear fashion.
19. 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
20. 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
21. 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
22. Connect the insufflator to the optical port and switch on the gas.
23. To begin with, an overview inspection of the entire abdomen must be done and noted.
24. 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.
25. Use the baseball diamond concept to mark the position of the additional 5 mm ports.
26. 15 to 30 degree Trendelenburg tilt aids in moving the bowel to the upper abdomen.
27. 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.
28. 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.
29. The uterine manipulator can be used to lift up the uterus for proper visualization.
28. Grasp the ovary which has undergone torsion with an atraumatic grasper and with tritome puncture the cyst and aspire the contents.
29. Undo the torsion with the help of 2 graspers.
30. Wait for 3-5 minutes for the blood supply to return.
31. If the color changes to pink, then remove the cyst wall and plicate the round ligament so as to prevent further torsion in the future
32. If there is no color change, then the ovarian tissue has become gangrenous and has to be removed and so proceed with oophorectomy.
33. Clean the peritoneal cavity with suction irrigation. 
34. After ensuring complete hemostasis, deflate the abdomen, remove the ancillary port under the vision and the primary port removed along with trocar.
35. Primary port (10 mm) has to be closed with 2-0 vicryl or monocryl.
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