Laparoscopy COPY Flashcards
What tests are available to check for correct placement of the Veress needle?
- Direct intraperitoneal pressures measurement: immediate gas pressures on entry and 5 successive pressures <8mmHg. Highest sensitivity and specificity. - Aspiration test: attach a syringe filled with saline to open end of Veress needle and aspirating. Remove if bowel contents or urine aspirated; leave in place and prep for laparotomy if blood aspirated. If no material aspirated, 5mL of saline is inserted and reattempt to aspirate. If not fluid is aspirated, entry into peritoneal cavity is confirmed. If saline is aspirated, and enclosed space was probably entered and needle should be repositioned. - Hanging/saline drop test: place a drop of saline on open end of Veress needle and lifting the abdominal wall; if needle is correctly positioned, water should disappear down shaft.
Which artery is most commonly at risk of damage during the placement of a low lateral secondary port? Briefly describe the anatomy of this artery and the practical steps that can be taken to avoid injury to this vessel.
Inferior epigastric artery. Risk of vascular damage 0.1 per 1000 Arises from external iliac artery immediately before it course under inguinal ligament. Runs medial to deep inguinal ring and then courses superiorly from inguinal ligament in transversalis fascia. It passes below arcuate line to run between posterior leaf of the sheath and rectus abdominis muscle, till it anastomoses with superior epigastric artery. Visualise lateral umbilical ligament prior to port placement; place port under direct vision.
How common is the risk of serious complications in laparoscopy?
1-2 in 1000
What factors increase the risk of complications in laparoscopic surgery?
Overweight. Underweight. Previous midline abdo incisions. Previous peritonitis or inflammatory bowel disease.
What are the indications for Palmer’s point entry?
Concerns for adhesions at umbilicus (incl previous midline laparotomy) Umbilical hernia Previous umbilical hernia repair
Describe the anatomical location of Palmer’s point
In LUQ, 2-3 cm below the left costal edge in the midclavicular line.
What structure should you identify when inserting secondary ports? Describe the anatomical landmarks used to identify this.
Inferior epigastric vessels. Lie just lateral to the medial umbilical ligament.
What patient characteristics increase the risk of vascular injury during laparoscopic entry?
Young. Slim. Nulliparous. Well developed abdominal musculature. Aorta may be less than 2.5 cm below the skin.
What is the rate of urological injury and what is most common?
0.3-1 per 1000 Bladder more common than ureteric damage 95% bladder injuries occur at dome, <5% involve trigone
How do you check intra-op and post-op for bladder injury?
- See injury or foley catheter bulb in the abdomen - Air inflating catheter bag - Methylene blue in 200-500ml saline through IDC - cystoscopy for ureteric jets and check for signs injury post-op - Oligo/anuric - High drain output - send for creatinine level - CT scan - fluid collection
What is the management for bladder injury?
- Inform SMO, anaesthetist, consider informing urology - If any concern for trigone damage - do cystoscopy - If <1cm - can consider conservative Rx - If bladder dome injured - close in 2 layers with absorbable suture (e.g. 3/0 vicryl). - Consider methylene blue infusion to check water tight repair - Place IDC for 7-10 days - Plan cystogram to check repair prior to TROC - Document - Debrief patient - Arrange clinic follow-up
Where are the common sites of ureteric injury?
1) At the pelvic brim when ligating the IP ligament - during ligation of IP ligament ureters run medial to the ovarian vessels esp if there is a large ovarian /paraovarian cysts, residual or ovarian remnant syndrome 2) Ligation of the uterine artery (most common) - at the base of the broad ligament where it passes underneath uterine arteries) 3) closure of the angles of the vaginal cuff - At the vaginal angles at the conclusion of hysterectomy, where it can be incorporated into haemostatic sutures 4) When clamping pedicles around a cervical or broad ligament fibroid - When clamping pedicles around a cervical or broad ligament fibroid as the ureter could be anterior, lateral, or posterior to the fibroid depending on the tissue distortion
What are the 6 commonest mechanisms of ureteric injury?
Crushing Kinked or ligated with a suture Transsecton (partial or complete) Angulation of the ureter with secondary obstruction Ischaemia from ureteral stripping or electrocoagulation Resection of a segment of ureter
How can you detect ureteric injury?
Intra op: - IV indigo carmine - enables structures of the urinary tract to be seen in the surgical field, and demonstrate if there is a leak - Careful inspection of the urinary tract and dissection of the ureters to assess the anatomical course and integrity - Intraoperative ureteral catheterization - Cystoscopy to look for jets followed by retrograde ureteropyelography to localise a ureteric lesion- extravasation of contrast confirms a ureteric injury - retrograde ureteral dye injection Postoperative presentation is variable – abdo pain, fevers, flank pain, ileus - FBC and urea, creatinine and electrolytes - Post-op if ureteric injury suspected then CT IV urogram is the gold standard (assesses the function of the ipsilateral kidney and drainage of the ureter), CT contrast abdo/pelvis with IV contrast may reveal urine within peritoneal cavity.
How is ureteric injury managed?
Upper third (extends from the upper border of the SI joint to the ureteropelvic junction)
- End-to-end reanastomosis
- can mobilise the kidney and fix it to the psoas tendon to reduce tension (helps with the left kidney but not the right)
- Nephrostomy should be inserted for delayed recognition of injury or when it is not amenable to primary repair
Middle ureter (upper border to lower border of SI joint )
- End to end reanastomosis also an option if transected cleanly
- -For more extensive injuries, or for when an anastomosis cannot be performed without tension then a Boari flap is used.
- Bladder is initially mobilised , rectangle flap created on the anterior surface of the bladder , flap is then sutured to psoas tendon to reduce tension , ureter is tunnelled through the proximal portion of the flap and a neo-orifice is created.
- Distal ureter is anastomsed to the flap . Anastomosis Is stented.
Lower ureter (inferior SI joint to uteterovesical junction) (Approximately 90% trauma ):
- 3-4cm proximal to the uterovesical junction: primary ureteral anastomosis + stenting if able to do so without tension
- 2cm from the uterovesical junction: reimplantation of the ureter
- Psoas hitch ureteral implantation is best approach when the above cannot be performed without tension
- Mobilise the bladder
- Cystotomy performed on anterior bladder wall of bladder away from dome, bladder then anchored to the psoas tendon
- Ureter then reimplanted
