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OBGYN > 6: PRINCIPLES OF OPERATIVE LAPAROSCOPY > Flashcards

6: PRINCIPLES OF OPERATIVE LAPAROSCOPY Flashcards

1
Q

Discuss double click test

A

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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2
Q

Double click test at umbilicus

A

2 clicks - Fascia, peritoneum

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3
Q

Double click test at LUQ

A

3 clocks - anterior fascia, posterior fascia, peritoneum

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3
Q

Explain saline aspiration test

A

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

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4
Q

Describe saline injection test

A

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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4
Q

Describe hanging drop test

A

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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4
Q

Intra-abdominal pressure test

A

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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5
Q

Normal entry pressure

A

0-7mmHg
<10 mmHg indicates correct placement

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6
Q

Average intraabdominal pressure with veress needle

A

4mmHg +/-2

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6
Q
A
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7
Q
A
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8
Q

Highest sensitivity test for intraperitoneal entry

A

Intraabdominal pressure

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9
Q

Sensitivity of intraabdominal pressure test for complications

A

79%

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10
Q

Sensitivity of intraabdominal pressure test for pre-peritoneal entry

A

100%

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11
Q

Tests with poor sensitivity/ppv for intraabdominal pressure

A

Double click test
Saline aspiration
Hanging drop test

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12
Q

Relative contraindications to umbilicial placement

A

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

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13
Q

Which entry is recommended?

A

SURGEON PREFERENCE - insufficient evidence to recommend one over the other

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14
Q

Indications for Palmer’s point

A

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

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15
Q

Distance of Palmer’s point from Stomach

A

4.5cm

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16
Q

Distance of Palmer’s point from L lobe of liver

A

5.6cm

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17
Q

Distance of Palmer’s point from pancreas

A

9cm

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18
Q

Distance of Palmer’s point from spleen

A

11.6cm

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19
Q

Distance of Palmer’s point from L kidney

A

14cm

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20
Q

Contraindications to Palmer’s point

A

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

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21
Q

How to do posterior vaginal fornix entry

A

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

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22
Q

Contraindications to posterior vaginal fornix entry

A

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

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23
Q

Overall rate of LSC complications

A

5%

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24
Q

% of LSC injuries not recognized intraoperatively

A

25%

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25
Q

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

A

1/3

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26
Q

Incidence of LSC entry injuries

A

0.3%

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27
Q

Most common location for LSC entry injuries

A

Umbilicus

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28
Q

Frequency of umbilical adhesions with no prior surgical hx

A

0.68%

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29
Q

Frequency of umbilical adhesions with hx LSC surgery

A

1.6%

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30
Q

Frequency of umbilical adhesions with hx low transverse incision

A

19.8%

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31
Q

Frequency of umbilical adhesions with MLV incision

A

51.7%

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32
Q

Correlation between umbilicus and aortic bifurcation in normal weight patient

A

Umbilicus 4mm caudad to aortic bifurcation

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33
Q

Correlation between umbilicus and aortic bifurcation in overweight patient

A

Umbilicus ~2cm below aortic bifurcation

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34
Q

Correlation between umbilicus and aortic bifurcation in obese patient

A

Umbilicus ~3cm below aortic bifurcation

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35
Q

Recommended angle in degrees of umbilical entry in normal weight patient

A

30deg

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36
Q

Recommended angle in degrees of umbilical entry in overweight patient

A

45deg

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37
Q

Recommended angle in degrees of umbilical entry in obese patient

A

90deg

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38
Q

Incidence of trochar site hernia

A

0.21-3.2%

39
Q

% of trochar hernias that occur DESPITE fascial closure

A

20%

40
Q

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

A

LSC 3.3%
Open abdominal surgery 12%

41
Q

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

A

Bladed trochar

42
Q

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

A

~50% smaller fascial defect

43
Q

Should you close fascia on open hasson case?

A

Yes- because fascial defect is larger than the trochar

44
Q

Hernia incidence at tissue extraction site if not periumbilical/midline

A

7%

45
Q

Hernia incidence at tissue extraction site if periumbilical/midline

A

24%

46
Q

Area that is at lowest risk of hernia

A

Transverse/suprapubic site

47
Q

What is the terminal branch of the external iliac?

A

Inferior epigastrics

48
Q

What is immediately medial to round ligament?

A

Inferior epigastrics

49
Q

Safe distance from umbilicus to avoid epigastric injury

A

<4cm or >8cm from midline

50
Q

Angle at which accessory trochars should be placed

A

90deg from patient’s skin

51
Q

Transuterine insufflation location

A

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

52
Q

Trans cul-de-sac insufflation

A

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

53
Q

Contraindications for trans-cul-de-sac insufflation

A

Advanced endometriosis
Large uterine fibroid
Adnexal mass

54
Q

Risk of morcellation with occult malignancy

A

Dissemination of tissue
Upstaging of disease
Particular concern with LMS

55
Q

Occult malignancy risk with LMS

A

1/495 - 1/8,000

56
Q

Risks of morcellating benign disease

A

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

57
Q

Patient population to avoid morcellation in

A

Menopausal women (especially if enlarging or newly symptomatic fibroids)

58
Q

Plain gut 50% loss of tensile strength in days

A

3-5 days

59
Q

Chromic 50% loss of tensile strength in days

A

7-10 days

60
Q

Polyglecaprone 50% loss of tensile strength in days

A

7 days

61
Q

Polylycomer 50% loss of tensile strength in days

A

14-21 days

62
Q

Polyglactin 50% loss of tensile strength in days

A

21 days

63
Q

Polydiaoxanone 50% loss of tensile strength in days

A

28-42 days

64
Q

Barbed Polydioxanone 50% loss of tensile strength in days

A

28-42 days

65
Q

Plain Gut 100% loss of tensile strength in days

A

14-21 days

66
Q

Chromic gut 100% loss of tensile strength in days

A

14-21 days

67
Q

Polyglecaprone 100% loss of tensile strength in days

A

21 days

68
Q

Polylycomer 100% loss of tensile strength in days

A

28 days

69
Q

Polyglactin 100% loss of tensile strength in days

A

28 days

70
Q

Polydioxanone 100% loss of tensile strength in days

A

90 days

71
Q

Barbed polydioxanone 100% loss of tensile strength in days

A

90 days

72
Q

Plain gut 100% mass absorption

A

70 days

73
Q

Chromic 100% mass absorption

A

90-120 days

74
Q

Polyglecaprone 100% mass absorption

A

91-119 days

75
Q

Polylycomer 100% mass absorption

A

90-110 days

76
Q

Polyglactin 100% mass absorption

A

56-70 days

77
Q

Polydioxanone 100% mass absorption

A

183-238 days

78
Q

Barbed polydioxanone 100% mass absorption

A

180

79
Q

What has superior knot strength, synthetic or natural suture?

A

Natural has superior knot strength

80
Q

Examples of natural sutures

A

Silk, chromic

81
Q

Does monofilament or braided have increased suture memory?

A

Monofilament (therefore suture handling can be more difficult)

82
Q

Recommended suture gauge for fascia

A

0 or 1

83
Q

Recommended suture gauge for vaginal cuff

A

0 or 2

84
Q

Recommended suture gauge for bowel

A

2

85
Q

Recommended suture gauge for skin

A

4

86
Q

Recommended suture length for extracorporeal suture

A

> 70cm

87
Q

Recommended suture length for interrupted intracorporeal suture

A

10cm

88
Q

Recommended suture length for figure of 8 intracorporeal suture

A

15cm

89
Q

Recommended suture length for continuous intracorporeal suture

A

30cm

90
Q

Cutting needle is best for what kind of tissue?

A

Tough tissue (ex: skin)

91
Q

Reverse cutting needle is best for what kind of tissue?

A

Tough tissue (ex: skin)

92
Q

Taper needle is best for what kind of tissue?

A

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

93
Q

MOA of adhesions

A

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

94
Q

Consequences of adhesions

A

Infertility
Intestinal obstruction
Chronic pain
Increased surgery complexity for next procedure

95
Q

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

A

90%

96
Q

Other causes of adhesion formation

A

Inflammation and infection, radiation

97
Q

Surgical technique for adhesion prevention

A

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

98
Q

Laparoscopic advantages to decreasing adhesion promation

A

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

99
Q

3 FDA-approved barrier methods for prevention of adhesion formation

A

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

100
Q

Goal for barrier methods to decrease adhesions

A

Maximize fibrinolysis by keeping damaged peritoneal surfaces apart

OBGYN (16 decks)

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