Operative laparoscopy in advanced pregnancy beyond 20 weeks TOG 2020

Question 1

What % of women require non obstetric surgery during pregnancy

Answer 1

0.5-2%

Question 2

Top tips for laparoscopy in advance pregnancy

Answer 2

1. Ensure an experienced surgeon and anaesthetist are present
2. Give antacid prophylaxis
3. Consider nasogastric tube insertion
4. Apply a left lateral tile to avoid aortocaval compression
5. Perform any change of position slowly
6. Consider using Hasson entry (supra-umbilical incision)
7. Consider Palmer’s point entry
8. Consider the use of ultrasound to facilitate entry
9. Use operating pressures of 10–12 mmHg
10. Auscultate the fetal heart prior to and after surgery

Question 3

Port locations

Answer 3

Primary point - palmers or supra-umbilical (3-6cm above umbilicus). Can consider USS before or use Visiport.

Do not instrument uterus

Question 4

Which degree scope and electrosurgery

Answer 4

30 degree scope
Bipolar electrocautery

Question 5

Describe Hasson Technique

Answer 5

A 10-mm incision is made horizontally at the umbilicus (Figure 2), which is then everted using Littlewood forceps
A Langenbeck retractor is used to facilitate access to the deeper layers of the anterior abdominal wall
Sharp, blunt dissection is performed to expose the umbilical stalk, which is grasped by Littlewood tissue forceps and delivered into the wound (Figure 3)
A 1-cm vertical incision is made in the umbilical stalk, incising the linea alba
The linea alba is grasped by two Dunhill artery forceps on either side and the peritoneum is opened under direct vision using a knife or scissors (Figure 4)
The incision is checked with the tip of the finger to ensure no adherent bowel loops
The trochar is inserted under direct vision (Figure 5) and the pneumoperitoneum created by connecting the CO2 insufflator to the trocar to an initial pressure of 20 mmHg (this can be reduced later to maintenance of 12 mmHg)5
A 360° check is performed.

Question 6

Explain palmer entry

Answer 6

Clinical examination is performed before incision to ensure no splenomegaly
Consideration is given to emptying the stomach with an orogastric or nasogastric tube
A small incision is made with a scapel in the left mid-clavicular line, 2–3 cm below the costal margin, and the Veress needle is inserted so it enters the skin perpendicularly (Figure 6)
Palmer’s (Figure 7) and pressure profile tests are performed to check for correct intraperitoneal placement
Insufflation with CO2 is performed to 20 mmHg (which can be reduced later to a maintenance level of 12 mmHg)5
The incision is increased to 5 or 10 mm to allow trochar insertion
The trochar is inserted into the pneumoperitoneum and a 360° check is performed.