6: PRINCIPLES OF OPERATIVE LAPAROSCOPY Flashcards by Samii Borno

Discuss double click test

Used with Veress needle to assess for appropriate intraabdominal entry
Palpable and audible click of spring-loaded obturator as the needle passes through layers of the abdominal wall

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Double click test at umbilicus

2 clicks - Fascia, peritoneum

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Double click test at LUQ

3 clocks - anterior fascia, posterior fascia, peritoneum

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Explain saline aspiration test

Attach syringe to veress needle
If blood aspirated - intravascular placement
If feces aspirated - in bowel
Nothing aspirated - appropriate entry

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Describe saline injection test

Attach syringe to veress needle
If high resistance or no flow - pre-peritoneal placement or adhesive disease
Minimal or no resistance - proper placement

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Describe hanging drop test

Saline in top of veress needle hub - if fluid moves freely down without pressure or movement, proper placement
If fluid does not freely flow, obstruction is indicated (ex: improper placement with pre-peritoneal location or adhesive disease)

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Intra-abdominal pressure test

Normal entry pressure 0-7mmHg
Average with Veress needle 4mmHg +/-2
Tubing should be attached and CO2 should be flowing
<10mmHg indicates correct placement

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Normal entry pressure

0-7mmHg
<10 mmHg indicates correct placement

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Average intraabdominal pressure with veress needle

4mmHg +/-2

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Highest sensitivity test for intraperitoneal entry

Intraabdominal pressure

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Sensitivity of intraabdominal pressure test for complications

79%

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Sensitivity of intraabdominal pressure test for pre-peritoneal entry

100%

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Tests with poor sensitivity/ppv for intraabdominal pressure

Double click test
Saline aspiration
Hanging drop test

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Relative contraindications to umbilicial placement

Periumbilical adhesions
Abdominal mesh
Extremes of weight
Umbilical hernia
Pregnancy (2nd tri)
Large pelvic mass

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Which entry is recommended?

SURGEON PREFERENCE - insufficient evidence to recommend one over the other

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Indications for Palmer’s point

Periumbilical adhesions
Hernia repair with mesh
Failed umbilical entry
Extreme obesity (umbilicus shifts significantly caudal)
Pregnancy

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Distance of Palmer’s point from Stomach

4.5cm

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Distance of Palmer’s point from L lobe of liver

5.6cm

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Distance of Palmer’s point from pancreas

9cm

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Distance of Palmer’s point from spleen

11.6cm

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Distance of Palmer’s point from L kidney

14cm

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Contraindications to Palmer’s point

Bariatric surgery (ex: gastric bypass, gastric sleeve)
Splenectomy/prior spleen surgery
HSM
Portal hypertension
Gastropancreatic masses
Upper abdominal adhesions

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How to do posterior vaginal fornix entry

Small colpotomy, then place veress need into cavity, insufflate and then can do abdominal trochar entry

Contraindications to posterior vaginal fornix entry

If mass is filling posterior cul-de-sac or if obliterated cul-de-sac

Overall rate of LSC complications

% of LSC injuries not recognized intraoperatively

25%

Fraction of LSC injuries that occur at time of initial abdominal entry

1/3

Incidence of LSC entry injuries

0.3%

Most common location for LSC entry injuries

Umbilicus

Frequency of umbilical adhesions with no prior surgical hx

0.68%

Frequency of umbilical adhesions with hx LSC surgery

1.6%

Frequency of umbilical adhesions with hx low transverse incision

19.8%

Frequency of umbilical adhesions with MLV incision

51.7%

Correlation between umbilicus and aortic bifurcation in normal weight patient

Umbilicus 4mm caudad to aortic bifurcation

Correlation between umbilicus and aortic bifurcation in overweight patient

Umbilicus ~2cm below aortic bifurcation

Correlation between umbilicus and aortic bifurcation in obese patient

Umbilicus ~3cm below aortic bifurcation

Recommended angle in degrees of umbilical entry in normal weight patient

30deg

Recommended angle in degrees of umbilical entry in overweight patient

45deg

Recommended angle in degrees of umbilical entry in obese patient

90deg

Incidence of trochar site hernia

0.21-3.2%

% of trochar hernias that occur DESPITE fascial closure

20%

5yr incidence of hernia after LSC surgery vs open abdominal surgery

LSC 3.3% Open abdominal surgery 12%

Which makes a bigger fascial defect - bladed trochar or dilating trochar?

Bladed trochar

Dilating trochars can make ~__% ___ fascial defects compared to bladed

~50% smaller fascial defect

Should you close fascia on open hasson case?

Yes- because fascial defect is larger than the trochar

Hernia incidence at tissue extraction site if not periumbilical/midline

Hernia incidence at tissue extraction site if periumbilical/midline

24%

Area that is at lowest risk of hernia

Transverse/suprapubic site

What is the terminal branch of the external iliac?

Inferior epigastrics

What is immediately medial to round ligament?

Inferior epigastrics

Safe distance from umbilicus to avoid epigastric injury

<4cm or >8cm from midline

Angle at which accessory trochars should be placed

90deg from patient's skin

Transuterine insufflation location

Veress needle through fundus Then insufflate to allow other port placement Need to ensure uterus is not deviated and in steep trendelenberg to reduce bowel injury

Trans cul-de-sac insufflation

Veress needle through vaginal fornix Can insufflate and then decrease risk of injury for other ports Need steep trendelenberg

Contraindications for trans-cul-de-sac insufflation

Advanced endometriosis Large uterine fibroid Adnexal mass

Risk of morcellation with occult malignancy

Dissemination of tissue Upstaging of disease Particular concern with LMS

Occult malignancy risk with LMS

1/495 - 1/8,000

Risks of morcellating benign disease

Dissemination of tissue Can result in parasitic leiomyomatosis Endometriosis can be iatrogenically caused

Patient population to avoid morcellation in

Menopausal women (especially if enlarging or newly symptomatic fibroids)

Plain gut 50% loss of tensile strength in days

3-5 days

Chromic 50% loss of tensile strength in days

7-10 days

Polyglecaprone 50% loss of tensile strength in days

7 days

Polylycomer 50% loss of tensile strength in days

14-21 days

Polyglactin 50% loss of tensile strength in days

21 days

Polydiaoxanone 50% loss of tensile strength in days

28-42 days

Barbed Polydioxanone 50% loss of tensile strength in days

28-42 days

Plain Gut 100% loss of tensile strength in days

14-21 days

Chromic gut 100% loss of tensile strength in days

14-21 days

Polyglecaprone 100% loss of tensile strength in days

21 days

Polylycomer 100% loss of tensile strength in days

28 days

Polyglactin 100% loss of tensile strength in days

28 days

Polydioxanone 100% loss of tensile strength in days

90 days

Barbed polydioxanone 100% loss of tensile strength in days

90 days

Plain gut 100% mass absorption

70 days

Chromic 100% mass absorption

90-120 days

Polyglecaprone 100% mass absorption

91-119 days

Polylycomer 100% mass absorption

90-110 days

Polyglactin 100% mass absorption

56-70 days

Polydioxanone 100% mass absorption

183-238 days

Barbed polydioxanone 100% mass absorption

180

What has superior knot strength, synthetic or natural suture?

Natural has superior knot strength

Examples of natural sutures

Silk, chromic

Does monofilament or braided have increased suture memory?

Monofilament (therefore suture handling can be more difficult)

Recommended suture gauge for fascia

0 or 1

Recommended suture gauge for vaginal cuff

0 or 2

Recommended suture gauge for bowel

Recommended suture gauge for skin

Recommended suture length for extracorporeal suture

>70cm

Recommended suture length for interrupted intracorporeal suture

10cm

Recommended suture length for figure of 8 intracorporeal suture

15cm

Recommended suture length for continuous intracorporeal suture

30cm

Cutting needle is best for what kind of tissue?

Tough tissue (ex: skin)

Reverse cutting needle is best for what kind of tissue?

Tough tissue (ex: skin)

Taper needle is best for what kind of tissue?

Soft tissue (ex: bowel, bladder, vaginal cuff) Has a rounded tip

MOA of adhesions

Peritoneal damage > bleeding and inflammation > fibrinogen > fibrin matrix > migration of fibroblasts and development of collaged (fibrinolysis is inhibited) > adhesions

Consequences of adhesions

Infertility Intestinal obstruction Chronic pain Increased surgery complexity for next procedure

Suggested that ~___% of abdominal operations lead to post-op adhesions

90%

Other causes of adhesion formation

Inflammation and infection, radiation

Surgical technique for adhesion prevention

Minimize tissue drying (via use of liberal irrigation) Minimize manipulation Shortest surgery time possible Adequate hemostasis Use electrosurgery judiciously

Laparoscopic advantages to decreasing adhesion promation

Decreased tissue drying Decreased tissue contamination d/t closed nature of procedure Pneumoperitoneum helps facilitate hemostasis Magnification/increased visualization helps facilitate hemostasis

3 FDA-approved barrier methods for prevention of adhesion formation

Oxidized regenerated cellulose Icodextrin 4% solution (Adept) Modified hyaluronate carboxymethylcellulose

Goal for barrier methods to decrease adhesions

Maximize fibrinolysis by keeping damaged peritoneal surfaces apart