Task Analysis of Laparoscopic Fallopian Tubal Recanalization
Task Analysis of Laparoscopic Fallopian Tubal Recanalisation
DR.LAKSHMI SREE ATMURI [ MS OBGY, F.MAS, D.MAS]
Surgical approximation of tubal segment after tubal sterilization or excision of an occluded or diseased portion of the fallopian tube
INDICATIONS: Desire for fertility
Normal semen analysis
Age more than 40yrs
Tubal sterilization previously by modified Pomeroy, fallopian rings, Filshie Clips
HSG to assess the length of the fallopian tube
Age more than 40 yrs
Decreased ovarian reserve
Extensive tubal damage
Tubal length less than 3cm
Severe male factor infertility
Respect to the delicate nature of the tissue
Minimum use of energy sources
Irrigate abdominal cavity with normal saline to minimum drying or adhesion
- Patient in lithotomy position under general anesthesia
- Foleys catheterization
- Check veress needle for its spring action and patency
- Take 2allis forceps to evert and hold each side of umbilicus
- Use number 11 blade to place small horizontal stab wound on the inferior crease of umbilicus
- Mosquito artery to dissect subcutaneous adipose tissue and expose rectus sheath
- Measure abdominal wall thickness and add 4cm for distance to hold veress needle
- Veress needle should be held like a dart
- Lift suprapubic part of abdominal wall with the left hand
- Insert veress needle in stab incision with 45-degree elevation angle and distal end pointed towards anus and perpendicular to the abdominal wall
- The surgeon can hear 2 click sound and maintain the 45-degree angle
- Confirm correct veress needle placement by irrigation test, aspiration test, and hanging drop test
- Connect carbon dioxide gas tube to veress needle
- Check quadromanometry for intraperitoneal placement of veress needle
- Ideal preset pressure of 12mmhg, maximum of 15mmhg
- The flow rate of 1lit/min
- Check uniform distension of abdomen and obliteration of liver dullness
- Once pneumoperitoneum is achieved remove veress needle
- Take cannula of 10mm and mark its impression on the skin
- Extend incision to the size of cannula impression
- Introduce 10mm port by holding it like a piston, perpendicular to the abdomen
- Confirm intraabdominal placement of port by escaping air sound and audible click
- Take out trocar
- Set flow rate increased to 6lit/min
- Connect gas tubing to the primary port
- Insert telescope
- Inspect entry point to exclude any bowel or vessel injury
- Request for Trendelenburg of 30-degree position
- Perform diagnostic laparoscopy with special attention to tubes
- Insert uterine manipulator to aid ease of suturing fallopian tubes
- Secondary and tertiary port placement with help of baseball diamond principle
- Ipsilateral port placement may be desired
- Vasopressin 5IU diluted in 20ml normal saline is injected into mesosalpinx with help of aspiration needle
- Dissecting scissors in the dominant hand
- Maryland forceps on another hand
- Excise occluded area of the tube
- Freshen up the ends of the fallopian tube
- Minimize injury to mesosalpinx
- Preferred suture 4-0 vicryl cutting edge needle
- First Mesosalpinx is to be approximated, to prevent tension over the tube and also anastomosis becomes easy
- Surgeon knots to be applied
- Avoid torsion of tube
- Avoid catching tube directly with a grasper or any other instrument
- Seromuscular sutures are placed at 6, 10, 2* clock position on right fallopian tube
- Seromuscular sutures are placed at 6, 10, 2* clock position on left fallopian tube
- Patency of the tube can be checked
- stop insufflation
- remove all ports under the vision
- close port sites 10mm port with help of veress needle, or port closure devices
Position the patient in the supine position.
Administer general anesthesia.
Insert a urinary catheter to empty the bladder.
Preoperative antibiotics are administered.
Make a 10-12mm incision at the level of the umbilicus.
Use a Veress needle to insufflate CO2 into the abdomen.
Insert a 10mm trocar through the incision.
Insert a laparoscope through the trocar and visualize the abdominal cavity.
Identify the fallopian tubes and the site of previous sterilization.
Use a monopolar or bipolar electrosurgical device to make an incision at the site of previous sterilization.
Use a laparoscopic grasper to grasp the proximal end of the fallopian tube.
Use microscissors to make a small incision in the proximal end of the fallopian tube.
Repeat the same procedure for the distal end of the fallopian tube.
Use a microforceps to remove any scar tissue or sutures that may be present at the site of previous sterilization.
Use a guide wire to cannulate the proximal end of the fallopian tube.
Use a catheter or balloon catheter to dilate the proximal end of the fallopian tube.
Use a guide wire to cannulate the distal end of the fallopian tube.
Use a catheter or balloon catheter to dilate the distal end of the fallopian tube.
Use a 10-0 or 9-0 nylon suture to perform the anastomosis between the proximal and distal ends of the fallopian tube.
Use interrupted sutures to ensure a watertight closure.
Use a dye test to confirm patency of the anastomosis.
Inspect the pelvic organs and surrounding structures for any signs of bleeding.
Remove the laparoscope.
Remove the trocars.
Deflate the abdomen.
Close the incisions with sutures or staples.
Apply sterile dressing to the incisions.
The patient is awakened from anesthesia.
Extubate the endotracheal tube.
Move the patient to the post-anesthesia care unit.
Administer analgesics for pain management.
Monitor vital signs and urine output.
Check the dressing for bleeding or drainage.
Observe the patient for any signs of infection or complications.
Advise the patient to avoid strenuous activity for 2-4 weeks.
Advise the patient to avoid intercourse for 2-4 weeks.
Schedule a follow-up appointment.
Evaluate the patient's postoperative course.
Monitor for any complications, such as bleeding or infection.
Evaluate the patient's recovery of bowel and bladder function.
Adjust medication as needed.
Evaluate the healing of the incisions.
Provide the patient with a detailed report of the procedure and postoperative care.
Advise the patient on any potential complications or side effects of the procedure.
Provide the patient with instructions on follow-up appointments and monitoring.
Advise the patient on when to resume normal activities, such as driving, work, and exercise.
The patient follows up with the surgeon at regular intervals.
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May 21st, 2020 2:58 am
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Apr 28th, 2021 10:59 am
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