Module 9

Question 1

Indications for Elective vs. Urgent Vs. Emergency Diagnostic Lap

Answer 1

Elective: cancer staging, chronic pain
Urgent: SBO, ileus
Emergent: Trauma, iatrogenic injury, perforated viscus

Question 2

Lysis of adhesions

Answer 2

sharp, blunt, or energy sources can be used

Question 3

Dx lap of upper abdomen positioning

Answer 3

• Reverse trendelenburg position so abdominal contents shift caudad
• Consider footboard and leg safety strap if steep reverse Tburg
• May need liver retractor
• May needs biopsy and hemostasis tools, US/C-arm, and suturing capability

Question 4

where do you enter for dx lap of unknown etiology

Answer 4

LUQ and place ports laterally (surgeon and assistant on same size)

Question 5

Dx lap of liver

Answer 5

mass, bleeding cirrhosis

• Angle scope, tools for biopsy/hemostasis, may need US
• Anterior surface: May need adhesiolysis
• Posterior surface: may need liver retractor, use blunt instruments for retraction
• Avoid bx of vascular lesions

Question 6

Dx lap of anterior abdominal wall

Answer 6

looks for postop bleeding, adhesions, hernia, tumor

• need angled laparoscope (30deg)
• LUQ access is safest

Question 7

dx lap for pelvic pathology

Answer 7

• Arms tucked, Trendelenburg position
• Retraction of uterus: uterine manipulator, lap retractior, suture retraction
• Needs instruments for biopsy and hemostasis

Question 8

Dx lap for appy

Answer 8

tuck L arm or both arms
- trendelenburg position with right side up, lateral position

Question 9

Dx lap for small bowel

Answer 9

• 2 monitors: one near head and one near feet
• Runs from ligament of Treitz (LUQ) to ileocecal valve (RLQ)
• Place ports along L abdomen
• USE BLUNT GRASPERS and handle mesenteric fat rather than bowel wall
• Use systematic fashion, start at cecum and work proximally

Question 10

Dx lap SBO

Answer 10

• Initial entry under direct visualization
• Start at ileocecal valve with relatively collapsed bowel, and then identify area of obstruction
• Use care handling dilated bowel

Question 11

Dx lap for retroperitoneal structures (exposure kidneys, spleen, adrenal glands)

Answer 11

• Best accomplished by lateral position so intestinal contents fall away
• Semi-lateral position allows for both lateral and supine positions
• Want ports at costal margin for best visualization of kidneys and adrenal glands
• May need Tburg and reverse Tburg
• May need to mobilize the colon to access the kidneys and adrenal glands, and para-aortic lymph nodes above the bifurcaton
• RP structures below aortic bifurcation (nodes) are accessed by incision overlying peritoneum
  1. Be careful for vessels, ureters, bladder, spermatic cord, and nerves (genitofemoral, obturator, lateral femoral cutaneous nerve)
  2. Usually do not require lateral position
  3. Usually can do supine position w/ or w/o dorsal lithotomy

Question 12

Dx lap for trauma

Answer 12

• Should not have severe hemodynamic instability
• Arms tucked, one monitor on each side of patient
• Angled laparoscope for max maneuverability
• May be good for detecting injuries to diaphragm or GI tract
• Reduces non-therapeutic laparotomy rate