Task Analysis Of Laparoscopic Myomectomy

1. Laparoscopic Myomectomy should be under General Anesthesia.
2. Position of patient: at the time of the pneumo-peritoneum by Veress needle, patient should be placed supine with 10 to 20 degree head down (steep Trendelenburg's position) or supine position if the Veress needle will be inserted perpendicular, if the uterine manipulator will be used then patient will be in lithotomy position, during the surgery head should be 30 degrees down.
3. Patient return plate should be attached to the thigh.

                               
• Monitor CCD-camera, light source, insufflator with CO2 cylinder, electrosurgical generator, and suction irrigation system -all in one cart.
• 10mm port, 5mm ports x3, Veress needle, 10mm 30 degree telescope, Maryland, atraumatic-grasper, semi-traumatic grasper, monopolar hook, bipolar grasper, harmonic scalpel, cold scissors, 5mm myoma screw, 2 needle holder, 10mm tenaculum, motorized morcellator, suture material no1 Vicrly, knot pushers and suction cannula and tubing , vasopressin 5ml in 100ml NS. 

Surgeon should stand in the left side of the patient during Veress needle insertion and opposite to the side of pathology to start surgery, monitor, target organ and surgeons visual axis in coaxial line, Camera assistant should be in the right side of the surgeon, 2 assistant surgeons one in the right side opposite to the main surgeon and the second for holding uterine manipulator, scrubbed nurse should be in left side of the surgeon, Preparation of parts done by scrubbing and draping under aseptic techniques.

Insufflator is turned on to remove air from tubing and set pressure is set at 20mm Hg, set flow rate set at 1 l/min, the camera is turned on focusing to be done at 10 cms, white balance to be adjusted. Set up the connections of require instrument bipolar/harmonic with the electrosurgical generator.

 
1. Take Veress needle and check for its spring action and patency.
2. Take 2 Allis forceps to evert and hold each side of the umbilicus.
3. Use number 11 blade to place small horizontal stab wound to the inferior crease of umbilicus.
4. Mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath. 
5. Measure abdominal wall thickness and add 4cm for distance to hold Veress needle.
6. Veress needle should be held like a dart.
7. The abdominal wall should be held full thickness with help of thenar, hypothenar and the entire four fingers.
8. At the time of insertion of Veress needle, there should be 45-degree elevation angle and the distal end of the Veress needle should be pointed toward the anus and also perpendicular to the abdominal wall.
9. The surgeon can hear and feel two clicks sound and Maintain a 45-degree angle.
10. Confirm correct Veress needle placement by irrigation test, aspiration test, plunger test and hanging drop test.
11. Connect CO2 gas tube to Veress needle and turn on CO2 and allow a flow rate of 1 L/min, insufflations pressure ideally should be 12 mmHg.
12. Observe Quadro-manometric indicators which include the preset insufflation pressure, actual pressure, gas flow rate and volume of gas consumed.
13. Once pneumo-peritoneum is achieved extend skin incision smiling shape and 11 mm in size.
14. Hold 10mm port like a gun and insert it perpendicular to abdomen & tilt to 60-70 degree towards pelvis when there is loss of resistance.
15. Confirm intra-abdominal placement of primary port with escaping air sound and an audible click and take out trocar.
16. Set the flow rate at 6 liters/minute.
17. Connect gas tubing to the primary port.
18. Insert telescope and inspect entry point to exclude any bowel or vessels injury.
19. Request for Trendelenburg of 30 degrees position.
20. Camera cable should be at 6 o’clock and the light source should be at 12 o’clock.
21. Apply the baseball diamond shape principle for lateral port insertion.
22. If the uterus is less than 12 wks size primary port is kept at the inferior umbilical crease, if the uterus is 14 to 18 wks size then the primary port will be supra-umbilical if the uterus is 20 wks size primary port should be placed at the palmar point.
23. Transilluminate at the target organ, the uterus with fibroids.
24. Incise skin along Langer lines for secondary ports x 2.
25. Insert lateral ports (5mm x 2 at LIF and RIF) at position of snuff box which is about 8cm from umbilicus should be placed high and outside the epigastric vessels so that good access is provided in case of ipsilateral ports -5mm port in left iliac fossa 3cms above the anterior superior iliac spine, another 5 mm port above and medial to previous port in LIF 5 cms away
26. All ports should be inserted perpendicular to the abdomen.
27. Diagnostic laparoscopy should be done first.
28. Relation of fibroid with the uterus and fallopian tube should be carefully assessed after inserting the primary port and then secondary ports should be decided according to the baseball diamond concept.

Incision of the myometrium and exposure of the Myoma: 
• Vasopressin 5ml of 1 in 100 dilutions injected at the stalk of the fibroid or considers preventive occlusion of the uterine artery.
• Now look for blebbing and pallor on fibroid due to vasopressin injected .this acts for 20-30 minutes.
• In case of an anterior myoma use oblique hysterotomy and in posterior myoma use sagittal hysterotomy.
• In the case of multiple fibroids, an incision is planned in such a way that maximum Myomas can be removed from one incision. 
• The hysterotomy is direct up with the myoma with harmonic scalpel or low voltage monopolar current in cutting mode until the capsule of the myoma is visualized

• With 2 graspers, cut edges are pulled so that the capsule is exposed and myoma screw is inserted.
• Now with myoma screw give gradual traction preferably anteromedial traction and counter traction with a blunt instrument like suction cannula and blunt dissection is done.
• Position of myoma screw is changed from time to time to apply traction on cleavage line until enucleation is done.
• The large feeding vessels at the base of the fibroid are cauterized with bipolar and cut with scissors or harmonic scalpel.
• Care is taken not to open the cavity.
• Undue use of cautery is avoided as it leads to defective healing and weak scar formation.
• Myoma after removal is placed in the cul-de-sac or para-colic gutters.
 

• Reconstruction of myoma bed is done with no 1 Vicryl suture.
• The main aim of suturing is to obliterate the dead space to avoid hematoma formation.
• Extracorporeal knotting technique is preferred.
• Start from one angle first suture should be placed beyond the angle.
• The rest of the defect is closed.
• The last suture should be beyond the other angle.
• The serosal layer is closed with Dundee jamming continuous suturing with Aberdeen termination.

 
• One of the ports is converted to 12mm and morcellator inserted.
• The myoma is held with a tenaculum and is fed to motorized morcellator.
• Take care not to move morcellator near the tissue instead of tissue to be fed to morcellator with a tenaculum.
• A meticulous lavage is given; hemostasis is checked and preceded for port closure.
• Port closure is done under vision with an outer sheath of Veress needle after slightly deflating the abdomen so that sutures are not in tension
• The last port to be closed is the telescope port, done after completely defeating the abdomen, and keeping the telescope in and removing the cannula followed by a telescope at last.
• The skin incision is closed with staplers and dressing done.