Golden Rules of Laparoscopyby Professor Achim Schneider

Dr Dirk Grothuesmann

http://dg-maternalhealth.de/

Frustration Alert

• Do not get overwhelmed by Number of Rules

• Study and apply them Step by Step

• Review them regularly

• Even your Teacher will violate them sometimes

• Add your own Rules if feasible

General Surgery

• Anatomic Rule Know them by Heart

• Obedience Rule Stick to the Rules

• No progress Rule Call for Help in Time

• Identical mistake Rule Do not repeat the same Mistake

• Communication Rule Inform the Patient and the Family

• Truth Rule Be honest, also to Yourself

Anatomy

Anatomy Rule

Anatomy is identically all over the World• Know the Anatomy by Heart

• You must know which anatomy Structure to preserve

• You must know which Structure you can transect, sacrifice or remove

• You must know which anatomical Variations you may run into and how to handle them

Bicycling is identically all over the WorldSo make it Safe for All

Anatomy is identically all over the WorldSo make Surgery Safe for All

Obedience Rule

Stick to Rules

• Follow the Rules rigorously to avoid Accidents

• Do not modify Rules unless proved otherwise

Time

No Progress Rule

Call for Help in a timely Fashion

• When there is no Progress in a Operation for more than 15 minutes call for help

Identical Mistake Rule

Do not repeat the same Mistake

• Every Surgeon makes Mistakes

• A good Surgeon does not repeat the same Mistake

Communication Rule

Communication Rule

Inform the Patient and her Family

• Always inform the Patient’s Family in the preoperative counselling

• Always inform the Family directly after the Operation about its Course

Truth Rule

Truth Rule

Be honest, also to Yourself

Ernst Ferdinand Sauerbruch (3 July 1875 – 2 July 1951)

• A bad Outcome is finally the Surgeons own Responsibility

• This Burden gets bearable through careful Diagnosis, adequate Skills and mindful Self-Awareness

• Best Basis is the Truth

• The Surgeon who tries to find Excuses for his Failure, disregards the most valuable Rule of his Guild

General – Laparoscopy

• Orientation Rule Optimal Orientation

• Visibility Rule Obtain good Imaging

• Information Rule Get close or pull away

• Overview Rule Get the maximal Overview

• Peek out Rule Never hold the Optic to far inside the Trocar

• Action Rule In the Center of the Monitor

General – Laparoscopy

• Golden Eye Rule Look always only at the Monitor

• Two Hands Rule Use both Hands

• Interaction Rule Support Progress in the operation Activity

• Alignment Rule Do not cross Instruments

• Rocking Ship Rule Keep it steadily

• Winning Position Rule Never change a winning Position

• Review Rule Watch your own Videos

Orientation Rule

Orientation Rule

Optimal orientation

• Orientation of Optic and Objects must match

• The Optic should be held always in the correct Orientation

• 12 o’clock on Screen is although 12 o’ clock on Screen

• Stick to the way God created us

• Water is always horizontal

Orientation Rule

Visibility Rule

Obtain good Image quality

• The Image must always be clear and in focus

• The Optic should always be clean

• Heating the Optic provides sharp and clear Image quality

• Coagulation generates smoke unintentionally, thus the Optic should be not to close to the Object

• Insufflate warm CO2

Visibility Rule

Visibility Rule

Foccus

• You can not depend on your Eyes when your Imagination is out of the focus

(Mark Train, November 30, 1835 – April 21, 1910)

Visibility Rule

Information Rule

Get close or pull away

• The imagine size should be optimal

• Vary the Distance between Optic and Object for the optimal View

• For Details move the Optic closer to the Object and magnify

• To have an Overview move the Optic away form the Object

Information Rule

Overview Rule

Get the maximal Overview

• The optic Trocar should be always in line with the abdominal Wall

• If the Trocar is to deep inside the abdominal Cavity you are too close to the Object and you will not get an Overview

Overview Rule

Correct

Overview Rule

False

Overview Rule

Get the maximal Overview

• Get the small Bowel out of the Pelvis

• Transect adhesions which block Exposure

Peek out Rule

Never hold the Optic to far inside the Trocar

• You should not see inside of Trocar but have complete Vision of your Object

Action Rule

Action Rule

In the Center of Monitor

• The Action has to be in the Center

• Hold the Camera as if you are the Surgeon

Golden Eye Rule

Golden Eye Rule

Look always at the Monitor

• The Assistant holding the Camera must always look at the Monitor

• “You are our Eye”

• Never look down

• Instruments are always and exclusively changed by the Nurse

Two Hands Rule

Use both Hands

• Use both Hands to manipulate one Instrument is each Hand

• Assistant holds the Optic with the left Hand and Instrument in the right Hand

• The Surgeon uses always two Instruments, one in each Hand

• Sleeping Hands are Forbidden

Two Hands Rule

Interaction Rule

Support the Progress in the Surgery interactively

• The Surgeon must interact

• There are always two Surgeons which interact and cooperate

• Interact actively with the other Surgeon and replace Instruments when needed

Alignment Rule

Do not cross Instruments

• Keep Instruments parallel to each other

• Place Trocars far form each other

Rocking Ship Rule

Keep it steadily

• Optic and Instruments must be kept steadily

• All Movements should be controlled

• Do not make hectic Movements neither with the Instruments now with the Optic

• You are not operating on a Ship

• Hold the Optic steady

Winning Position Rule

Never change a winning Position

• The Position of Optic and Instruments should be not changed if not required

• Do not make unnecessarily Changes when you are in a good Position

Review Rule

Watch your own Videos

• Review your own Videos when you have normal adrenalin Level

• Watch Videos of your Coworkers and other Surgeons whenever possible

Technique• Bladder Rule Bladder filling and emptying

• Support Rule use Belts and Shoulder support

• Size of Incision Rule smaller than Trocar

• Careful Entry Rule shift first Entrance site to left subcostal Side

• Arrogance Rule never be to arrogant for an additional Trocar

• Optic Trocar insert Rule always insert vertically BUT

• Water and Bridge Rule know how to identify the Ureter Rule

• No Blood Rule apply preventive Coagulation

• Clean bipolar Rule always have a clean Bipolar

• Insertion of big Needle Rule every Needle can be inserted

• Reentry Rule use 5 mm Trocars and blunt Instrument

Bladder Rule

Bladder filling and emptying Rule

• Use System in order to fill and empty the Bladder

Support Rule

Use a Shoulder and Belt Supports

• Use strapping Belts and Shoulder Support in order to prevent sliding in deep Trendelburg Position

• Do not leave the Patient for more than 3 Hours in the same Position

Beware Compartment Syndrome

Size of Incision Rule

Size of Incision must be smaller than the Diameter of the Trocar

• This will prevent slipping of Trocar

• You can even omit Incision using a conical Trocar

Careful Entry Rule

Shift first Entry side to left subcostal Region in Case of

• Midline Incision by previous Laparotomy

• Previous unsuccessful Attempts through Umbilicus

• Preperitoneal Insufflation

• Pregnancy above 12 Week of Gestation

• History of Radiotherapy

Arrogance Rule

Never be to arrogance for an additional Trocar

• You may need additional Trocars and Instruments

• In obese Patients

• For save Dissection of Adhesions

• In Pregnancy

Optic Trocar insert Rule

Insert vertically is most save BUT

Water and Bridge Rule

Identify the Ureter

• The Water (Ureter) runs always under the Bridge (A. uterina)

• The Ureter is best identified at the Bifurcation of the common Iliac Artery

No Blood Rule

Support the “Sahara principle”

• Apply preventive Coagulation

• Only by preventive Coagulation anatomic Operation is possible

• Bleeding is the Enemy of the Surgeon

• Avoid using Suction Device during Surgery

• This will force you to avoid Bleeding

• There should be no Bleeding during and at the End of Operation

Clean Bipolar Rule

Always have a clean Bipolar

• Only a clean Bipolar can work

• To save Time keep a second Instrument ready

Insertion of big Needle Rule

Every Needle can be inserted

• Use big Needle for Metroplasty

• Pull Needle though abdominal Wall

Holding Suture Rule

Through Peritoneum, through Uterus

• Holding Suture

• Through Peritoneum for retroperitoneal Dissection

• Through Uterus for Exploration of Pouch of Douglas

Reentry Rule

Use a 5 mm Trocar

• When a 12 mm Trocar has to be removed and must be reinserted

• For Reestablishment of Pneumoperitoneum use a 5 mm Trocar for

• Use blunt Instrument rather than Mandrin of Trocar

• To re-insert Trocars use blunt Instruments

• For 10 mm Trocar a sponge-holding Forceps is feasible

Contamination Rule

Avoid Contamination of Trocar sides

• Use Endo-Bag or cut finger Glove

• Change Glove after handling Tumor

Faszia closing Rule

• Close Fascia Defects > 10 mm or any Trocar Side which became widened during Surgery

Complications

• Get better Rule Patient conditions improve constantly

• Collateral damage Rule avoid thermal Injury

• Stay cool, be prepared Rule always be ready

• Stay cool, be prepared Rule maintain Traction

• Marketing Rule mark the Injury Side

• Never say never Rule be suspicious about additional Injury

Get better Rule

Patient Condition improves constantly

• Postoperatively the Patient gets better every Day

• If not generously indicate Re-Laparoscopy in order to exclude Complications (e.g. Leakage of Bowel, Bladder, Ureter or Bleeding)

Collateral Damage Rule

Avoid thermal Injury Rule

• Do not use Coagulation to close Bowel, Bladder, Ureter or Nerves

• Make sharp Dissection close to these Structures and avoid Coagulation

Stay Cool, Be Prepared Rule

Know anatomic Variations

• Be aware about 30% anatomic Variations and vascular Anomalies in up to 30% of the Patients

• Remember older Women have more fragile Veins than younger Women

What is really needed?

NOT MUCH!

Stay Cool Be Prepared Rule

Always be ready

• Always keep these Instruments ready

• Suction

• Bipolar Forceps

• Alligator Forceps

• Clip Applicator

Stay Cool, Do Not Panic Rule

Make Compression and wait

• Small Bleedings can be managed by Compression for a few Minutes and, if necessary, careful bipolar Coagulation

Stay Cool, Do Not Panic Rule

Use Suction

• Coagulation in a Pool of Blood is impossible

• Use Coagulation and Suction in a heavy Bleeding

Stay Cool, Do Not Panic Rule

Maintain Traction

• Do not PANIC and do not release TENSION when it is Bleeding, rather make TRACTION

• Traction by Alligator Schneider Forceps reduces Blood flow effectively

Stay Cool, Do Not Panic Rule

Use Clips for large Vessels

• Bleeders larger than 2 mm are managed by Clipping

Marking Rule

Mark the Injury Side

• Immediately Mark the Injury Side by Suture on the Intestine

• Finding the Lesion on later might be impossible

Never Say Never Rule

Be suspicious about additional Injury

• Exclude an additional Injury Side in the event of Injury to Bowel, Bladder, Ureter

• Never be 100% sure that no other Injury has happened

• One Hole necessitates Exclusion of another Hole

Special Procedures

Lymphadenectomy

• Spider Web Rule follow the Spider Web

• Friendly Terrain Rule have no Fear of the Retroperitoneum

• Pulling Rule use no Scissors for Lymphadenectomy

• En bloc Rule do not violate oncologic Safety

• Walk the line Rule walk form one Lymph Node to the next

Spider Web Rule

Follow the Spider Net

• Dissection follows the natural Planes and Structures

• Let the CO2 Gas let its work

Spider Web Rule

Friendly Terrain Rule

Have no Fear of the Retroperitoneum

• The Retroperitoneum is the key to anatomical Surgery

• The Retroperitoneum is your Friend

• Always preserve the anatomical Structures of the Retroperitoneum

• Open the Retroperitoneum far lateral from the infundibulopelvicLigament to prevent Bleeding from injured Veins

Pulling Rule

Use no Scissors for Lymphadenectomy

• Lymph Vessels and small Blood Vessels can be torn after Coagulation

• Nerves and major Blood Vessels can not be torn and are protected using this Technique

En Bloc Rule

• Do not violate oncologic Safety

• Dissect Lymph Nodes en Bloc with Capsule intact

Walk The Line Rule

Walk from one Lymphnode to the next

• The surgical strategy of Lymphonodectomy is easy: the Lymphnodeshows the Way

Radical Hysterectomy and TrachelectomyRule

• Vaginal Cuff Rule close the Cuff and Vault tight

• Landmark Rule follow the anatomic Nerves

• Raw Egg Rule be careful with Ureter and Bladder

Landmark Rule

• Follow the automomic Nerves

• Identify the Hypogastric Nerves and Pelvic Structures

• Never go lateral to these Structures

Raw Egg Rule

Be careful with Bladder and Ureter

• Ureter and Bladder are always jeopardized

• Noli me tangere

Suture Rule

Adequate Suture will secure Success

• Use always a big Needle

• Always hold the Knot tight prior to the second Knot

• For Metroplasty of big defects apply additional Stiches for Safety

Morcellation Rule

Morcellate only benign Fibroids

• If in doubt:

• Enucleate bluntly without touching the Myoma

• Morcellate in Endobag via Mini-Laparotomy

• If Patient is no longer seeking Parenthood advice for Hysterectomy and morcellate Specimen in Endobag

Rectovaginal Endometriosis

• Assessment Rule

• Resection Rule

• Nerve-sparing Rule

Assessment Rule

Extent of Disease is assessed intraoperativelyDisease is diagnosed by:

• Rectovaginal Examination

• Transvaginal Dissection

• Laparoscopic Evaluation

Imaging Techniques are inaccurate

Resection Rule

•Only anterior rectal Wall is involved

• Resection of Bowel Tube is sufficient

• Mesorectum is not resected

• Hand sutured Anastomosis is save

Nerve Sparing Rule

Autonomic Nerves must be spared

• Identify Splanchnic and Hypogastric Nerves

• If invaded by Enometriosis they may be sacrificed unilateral never bilaterally

LEEP Rules

• LEEP excision Rule LEEP Excision under Magnification

• Squamo-culmnar Junction Rule always Identify the Junction

• Archimedes Rule always measure the Conus

• Contact bleeding Rule always take a Biopsy

LEEP Rules

LEEP Excision under Magnification

• Identify the Lesion to be removed

• Minimize the Tissue Damage

Squamo-Columnar Junction Rule

Always identify SCJ

• Identify Type of Transformation Zone

• Use Endocervicoscopy in T-Zone Type III

Achimedes Rule

• Measure Volume of Cone

• Determine the Volume removed

Contact Bleeding Rule

Always take a Biopsy

• Do not rely on Cytology or Colposcopy

• No Destruction without prior Biopsy

for Histopathology

Acknowledgement

Thanks to the great and inspiring work of

Professor Achim Schneider and his team,

who have developed these Golden Rules

by a dedicated work of more than

20 years of gynecology surgery

Source:

http://www.mvz-fuerstenberg-karree.de/mediathek/

Aim of my Project

Dr. Dirk Grothuesmann ConsultancyImproving Maternal Health and Gynecology Services by Training Health Care Providers: Relaying on standardized training modules I teach evidence-based obstetrical procedures, gynecology surgery and related evaluation tools to local personnel in developed and developing countries. Completing the programs offered, skills gained enable to serve women in need in any requested setting.

http://dg-maternalhealth.de/index2.html

http://dg-maternalhealth.de/

Dr Dirk Grothuesmann Consultancy