Diagnostic Laparoscopy Task Analysis
Dr Yogesh Bodulkar 
Obstetrics and Gynaecology Registrar - Australia
DMAS Nov2016 Batch - World Laparoscopy Hospital;Gurgaon, India

Introduction:

• Case Selection for Operative Intervention:

- Indications for Gynaecological Diagnostic Laparoscopy
- Acute or Chronic Abdominal pain
- Endometriosis
- PID
- Infertility
- Ovarian Cyst, Ovarian Torsion
- Abdominal Trauma
- Pregnancy of Unknown location

• Consent and Booking Surgical Procedure:

- Written, Valid and Informed Consent obtained from patient. 
- Anaesthetic and Laparoscopic surgical procedural risk with possible conversion to Laparotomy explained and documented.
- Patient Booked for Surgery.

• Pre-Operative Investigations and Anaesthetic Evaluation:

- Obtained

• Pre-Operative Preparation:
 
- Instructions to patient about diet, bowel preparation and presentation to hospital on the day of surgerywith over-night fasting.

Day Surgery Admission:

- Confirmation of over-nightfasting status of patients and availability of a support person with patient. 
- Inquiring about medical issues; if any that mighthave been developed in the interim period while awaiting surgery which can be contraindication for surgical procedure.
- Confirm patients consent
- Introduce patient to Anaesthetic team

• Debriefing the Anaesthetic team and OT Team about the case.

• Ensure help is available in case if needed from appropriate faculty surgeons and OT Staff is aware of contact details of respective doctors. (eg: Surgical faculty team stand-by)

• Preparation of Surgical InstrumentTrolley:Ensure a sterilized Laparotomy Instrument set is available if required.

Equipment Cart / Laparoscopy Tower:

- Monitor (Desirable 26” HD)
- Light Source and Camera Control Unit (Desirable – LED light source and 3 Chip HD Camera)
- Insufflator and CO2 Gas Cylinder (Desirable – Microprocessor Controlled Computerized Insufflator and Medical Grade CO2)
- Electro Surgical Unit (Desirable – High Frequency Generators)
- Select Pre-set Pressure (Ideal 12 to 15mmHg)
- Video Recorder & Printer
- Suction Irrigation system
- Desirable to have Active Electrode Monitoring System (for eg:- AEM – END SHIELD)
Confirm functional status of these equipment’s.

Surgical Instrument Trolley:

Instruments used can be disposable or reusable. Confirm Sterilization & Functional status.

For Laparoscopy:

Selection of energy source as per preference of surgeon, surgical procedure (if Consent available) and availability at hospital 
Laparoscope – x1 (Desirable – HD); 30’ 5mm for Diagnostic, if any procedure to be performed then 10mm laparoscope needed
Insufflation tubing and light source cable
Veress' needle – 12 cm length
10 mm port (x 1) (if required)
5 mm port (x 2) – if additional procedure is to be performed then X2 Secondary ports are necessary
Laparoscopy Aspiration Needle (x1)
Laparoscopic scissors (x1)
Atraumatic grasping forceps (x1)
Tissue Dissection forceps (x1)
Suction Irrigation tubing (x1)
Set of Allis forceps
Set of Artery forceps
BP Handle (x1)
Surgical Blade No 11 (x1)
10 ml Syringe and Normal Saline (x1)
No 23G 1&1/2“Needle (x1)
Local Anaesthetic agent (Bupivacaine 0.5%)

For Vaginal Procedure:

In order to avoid contamination of the Laparoscopy instrument these instrument are placed on a separate 
trolley.

Sims Speculum (x1)
Vulsellum (x1)
Set of Hegar’s Cervical Dilators
Uterine Curette (x1)
Spackman Cannula (x1)

For Skin Closure:

Suture Material {3-0 Monocryl x1 and No 1 Vicryl x1 (if fascia closure required as in case of Open Access Technique)}
Needle Holder (x1)
Toothand Fine Forceps (x1)
Suture Cutting Scissors (x1)
Port Site Wound Dressing

(Note: In case of Morbidly Obese patient Laproscopy instrument’s used will be Bariatric)

Patient Surgery Safety Check and Anaesthesia:

- Carry out pre-operative patient safety check as per WHO Surgical Safety Check List.
- Anaesthesia induction process -General Anaesthesia as per Anaesthetic Team
- Antibiotic &/or VTE Thromboprophylaxis (as deemed necessary)
- Ensure application of Patient Return Electrode as per use of appropriate energy source – (100cm2eg: REM Polyhesive)

Patient Positioning:

- TEDS & SCUDS over lower limbs as VTE Prophylaxis measure
- Lloyd Davies position
- Confirm Surgeons position in relation to patient’s position and surgical procedure
- Adjust Height of table as per surgeon (Surgeons height X 0.49 or use platform to stand on it)
- Ideally co-axial alignment is needed - Surgeon, Target Organ, Monitor
- Monitor is placed at a distance of 5 times its diagonal length from the Surgeon
- Adjust Monitor height to 15’ to 20’ below surgeons eyesight level
- If possible make use of second monitors – for ease of the other assisting surgeon
- Ensure Insufflator display is easily visualized from Surgeon’s end
- Ensure Elector surgical energy source foot pedal is near the surgeon’s end and easily accessible to the surgeon
- Examination under Anaesthesia (EUA) -  Per Abdominal Examination, Speculum examination, Pap smear &/or Endocervical/High Vaginal Swab (if deemed necessary& pending)
- Determine Position of Surgical Team – Surgeon, Surgical Assistant, Scrub Nurse
- Preoperative skin preparation (Abdomen & Perineum with Povidone Iodine or Chlorhexidine) and Surgical Draping

Pre-Procedure in OT

- Primary Surgeon & Assisting Surgeon– Scrub
- Arrange Light source cable, Gas/Suction tubing, Electro Surgical Energy device cables
- Electrosurgical cables and Light source cables should not be together
- Focus camera (at distance of 10cm)
- Performs white balance through Telescope –on a white gauze piece spread over the entiremonitor screen without any other object or any other colour in the field of view)
- Check the Telescope

Procedure:

• Surgical Team Position:

- Primary Surgeon – Left side of patient
- Assistant Surgeon- Between the legs of the patient for Uterine manipulation
- Scrub Nurse – by the side of the Primary Surgeon
- Anaesthetic team at the head end of the patient

• Laparoscopy:

- Insufflation:

Closed Assess Technique with Veress Needle:

- Site – Inferior Crease of Umbilicus
- Hold umbilicus with Allis forceps on either side to evert the inferior crease of umbilicus
- Infiltrate the site of incision with 0.5% Bupivacaine local anaesthetic agent
- Make a stab incision of 2mm with No 11 surgical blade
- Check Veress Needle for spring action and patency
- Lift up the abdominal wall area below the umbilicus and assess its full thickness
- Veress Needle is held like a dart at a level of 4 plus thickness of abdominal wall in centimetres by its shaft.
- Insertion of veress needle through the incision site in a manner that the veress needle makes an angle of 90’ with the abdominal wall and an angle of 45’ with the body of patient
- Veress Needle insertion is aimed at the anus
- Insertion is achieved with two audible clicks; 1stof the Rectus Sheath and 2nd of the Peritoneum
- Release the Allis forceps and Abdominal wall
- Hold the Veress Needle at an angle of 45’ making sure that no further length of needle is advanced
- Placement of Veress Needle inside peritoneal cavityis confirmed by attachment of a 10ml Syringe filled with
Normal Saline and performing following tests:
a. Irrigation Test: Injecting 5ml of Normalsaline, free flow confirms placement inside the peritonealcavity
b. Aspiration Test: There should not be any returning fluid, confirms placement inside the peritoneal cavity
c. Hanging Drop Test: Drop of Normal Saline is placed at the hub of the Veress Needle and abdominal wall is lifted. Suction of this drop into the abdominal cavity confirms placement inside the peritoneal cavity
d. Plunger Test: Removing the plunger of the attached syringe; free flow of remaining Normal Saline in to the abdominal cavity confirms placement inside the peritoneal cavity.
- Ensure that the Gas tubing is attached to the Insufflator and the Insufflator is switched ON. This will remove air from the Gas tubing and fill the gas tubing till its tip with CO2 gas.
- Confirm Pre-Set Pressure to 15mmHg on the Insufflator
- Attach the gas tubing to the veress needle and start the flow of CO2gas at 1 liter per minute
- Find the minimum of the five reading onInsufflator; this will give us the Actual Pressure.
- Confirm obliteration of liver dullness and generalised distension of abdominal wall
- Keep watch on patient’s vital parameters and EtCO2 readings during insufflation
- Keep watch on the Insufflator reading of Actual Pressure, Flow of gas and Total amount of Gas used.
- The total amount of gas and actual pressure should rise parallel to each other
- When actual pressure has reached pre-set pressure and amount of gas used is 1.5 to 6 litres for an averagely build young patient
- Remove the veress needle from abdomen and start preparation for Primary port site insertion
- Primary Port Insertion
- Increase the size of the umbilical incision to 10 – 12mm and dissect the subcutaneous tissue upto the rectus sheath with an artery forceps
- Hold the 10mm port (Trocar with cannula) like a gun with index finger along the shaft, middle & ring finger wrapped around the gas vent and the port resting on to the thinner eminence of the palm and tip pointing towards the incision site
- Port is introduced through the incision in a rotating fashion pointing perpendicularly
- Once into the peritoneal cavity evident by an audible click and give-way sensation; direct the port at an angle towards the pelvis
- On removal of the trocar from the cannula a whooshing sound of escaping gas is audible, which further confirms entry into the abdominal cavity
- The gas tubing should now be connected to the primary port.
- Insert the telescope into the primary port and visualise the intra-abdominal entry. (White Balance & Focal length adjustment done earlier)
- Immediately inspect the abdomen below the primary port site for any signs of injury
    
Assisting surgeon:

- Insert simple urinary catheter and empty bladder
- Hold the cervix with Velsellum and measures the uterocervical length with a uterine sound
- Dilate the cervix upto 5mm Hegar’s dilator
- Insertion of Spackman’s cannula
- Assembly of Velsullum attached to the spackmans cannula can be used for uterine manipulation and for
Chromopertubation if required.
- Above is observed by the primary surgeon by laparoscopy

• Laparoscopy Procedure: Port position as per Base Ball Diamond Concept 

 Principles followed are: Laparoscopy instrument should behave like Type -1 lever with half instrument insideand half instrument outside the abdomen. Primary port at centre and secondary port 7.5cm on either side of it. This makes the angle of elevation of 30’ and manipulation angle of 60’ and azimuth angle of 30’.

Projection of target on to the anterior abdominal wall and secondary port placement 7.5cm on the left and right of the primary port. 

Secondary Port Position – Left Iliac Fossa:

Transillumination of the port site by the telescope avoiding the inferior epigastric vessels Infiltration of the incision site with local anaesthetic 5mm skin incision and insertion of 5mm port similar to as describe above for primary port; however under vision Once the port tip has tented the peritoneum and visualized in the peritoneal cavity then it is directed to the pelvis The Preset pressure is now adjusted to 12 mmHg

- If necessary a second can be introduced on the right side 7.5 cm from the Primary port or alternatively 5cm from the initial Left iliac fossa port. In case if patient is consented and any surgical procedure deemed necessary to be performed along with diagnostic laparoscopy.

• Systematic Survey of Abdomen & Pelvis:

Performed by Primary Surgeon with Telescope in right hand and Atraumatic grasper in the left hand; while the assistant siting between the legs of the patient help with anteversion, retroversion and side retraction of the of uterus

Abdomen:

- In steep Trendelenburg’s position - starting from Right Iliac fossa
- Caecum – Appendix –going cephalad – towards Right Hypochondrium
- Ascending colon–Hepatic flexure of Colon
- Remove steep Trendelenburg position –visualise Right lobe of Liver - Gall bladder –Stomach
- Crossing the Falciform ligament – visualise Left lobe of liver
- Coming towards the Left hypochondrium – Spleen
- Going down towards the left iliac fossa – Sigmoid colon

Pelvis:

- In steep Trendelenburg’s position
- Anterior pouch – Bladder, Utero-Vesical fold of peritoneum, Median ligament, Medial Ligaments, Coopers ligament
- Posterior pouch - Uterosacral ligaments,Rectum
- Uterus – Fundus, Anterior & Posterior surface
- Right & Left adnexal structures – Ovaries, Tubes, Round & Infundibulopelvic ligaments, Ovarian fossa & ligament
- Sacral Promontory
- Right & Left pelvis side wall – Deep ring, Ureters, Triangle of Doom, Trapezoid of Disaster
- Insitu findings are noted. Photos and video recording captured.
- If patient is consented for then any pathological findingcan managed laparoscopically
Or else suspicious areas can be biopsied and post-operative discussion with regards to further management of patient’s condition in light of Diagnostic Laparoscopy findings.

• Conclusion of Laparoscopy Procedure:

- Keep watch on patient’s vital parameters and Capnography reading.
- Stop insufflation and make note of Total amount of gas used during the surgery and total time of surgery.
- Ensure Haemostasis
- Confirm Instrument count
- Avoid sudden decompression of pneumoperitoneum and abrupt removal of ports
- Removal of Secondary Port under vision
- Precaution while removing Primary port - Do not abruptly remove the port. 
- Keep the telescope in the abdominal cavity and start withdrawing the cannula 
- Continue to observe this withdrawal process on the monitor
- Once the cannula has reach within the abdominal wall then start withdrawing the telescope
- Continue observing the withdrawal process on the monitor
- Remove the cannula and the Telescope under vision. 
- This process will avoid entrapment of Omentum or Bowel within the Primary port wound
- Primary Port fascia and Skin closed; Secondary Port Skin closed
- Fascia closed with Vicryl and Skin with fine Monofilament suture
- Abdomen cleaned and Port site wound dressing applied
- Uterine manipulator removed and Vaginal bleeding ruled out

• Patient position to now changed to Supine position.

• Await Anaesthetic reversal & extubation procedure and Shift Patient to Recovery area.

• Review and debrief patient about intra-operative findings (with Photos if printed) and briefly explaindischarge,further plan of management; once the patient has recovered from anaesthesia.

• Explain Red Flags to patient, so that patient can report to the hospital immediately.

• Provide Surgery Photos or Surgical Video to the patient.

• Provide Discharge Summary documenting Insitu findings of Diagnostic Laparoscopy&further Rx-follow-up plan.