RCOG Basic Practical Skills Course

Laparoscopy and entry

Royal College of Obstetricians and Gynaecologists

Laparoscopic entry techniquesWhat to expect:Position of patientPrimary port closed entrySecondary port entryPrimary port alternativesExit techniquesReference to RCOG Green Top Guideline 49 - PREVENTING ENTRY-RELATED GYNAECOLOGICAL LAPAROSCOPIC INJURIES

Royal College of Obstetricians and Gynaecologists

1. PositionProneStirrups/Lloyd Davis Non slip mattressTrendelenberg after ports

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008The operating table should be horizontal (not in the Trendelenberg tilt) at the start of the procedure

The abdomen should be palpated to check for any masses before insertion of the Veress needle

Royal College of Obstetricians and Gynaecologists

Why intra umbilical entry?

Fixed peritoneumThinLeast vascularCosmetic2. Primary port closed entry

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008The primary incision for laparoscopy should be vertical from the base of the umbilicus (not in the skin below the umbilicus)

Care should be taken not to incise so deeply as to enter the peritoneal cavity.

Royal College of Obstetricians and Gynaecologists

Insertion of Veress needlePencil gripVertical, then towards pelvisDouble click2. Primary port closed entry

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended

The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at right angles to the skin

Royal College of Obstetricians and Gynaecologists

Two audible clicks are usually heard as the layers of the umbilicus are penetrated.

Excessive lateral movement of the needle should be avoided. This may convert a small needle point injury in the wall of the bowel or vessel into a complex tearGreen-top Guideline. No. 49 May 2008

Royal College of Obstetricians and Gynaecologists

Saline testWithdrawInstilWithdraw

If no fluid, frank blood (or faeces) then proceed with insufflation2. Primary port closed entry

Royal College of Obstetricians and Gynaecologists

The saline test not 100% accurate

The most valuable test of correct placement of the Veress needle is to observe that the initial insufflation pressure is relatively low (less than 8mmHg) and is flowing freely

After 2 failed attempts to insert the Veress needle, either the open Hasson technique or Palmers point entry should be used.Green-top Guideline. No. 49 May 2008

Royal College of Obstetricians and Gynaecologists

InsufflationSet pressure cut off to at least 20-25mmHgStart at low flow (1L/min)Check gas entering at low pressure ( 7mm - Lateral port sites > 5 mm

Royal College of Obstetricians and Gynaecologists

Now show the Video: Closedlaparoscopic entry techniqueNow show the video: Alternativelaparoscopic entry techniques

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