Dr Radha K N
MBBS,DGO
Consultant Obstetrician & Gynaecologist
Omega multispeciality hospital, Yelahanka
Bengaluru, KARNATAKA.



1. Surgical team: Surgeon, Anaesthetist, Assistant, Scrub nurse

2. Equipment needed:
    a. Laparoscopic drapes, insufflator,Light source,HD camera with 30 degree telescope,Monitor, LCD monitor
    b. Veress needle
    c. Ports: One 10mm reusable port , one 5mm port
    d. Basic laparoscopic instruments - Atraumatic grasper, punch biopsy forceps, suction –irrigation cannula with  apparatus.
    e. Vicryl 1-0 round body needle, size no.11 blade, BPL handle,10mm syringe with saline, 10ml syringe with 2%xylocaine and skin staples

3. Method of anaesthesia: General Anaesthesia

4. Setting of the equipment
     a. Pre-set pressures of the insufflator to 12 – 15mmHg 
     b. White balancing with white gauze and focusing at about 10cm range

5. Position of patient:
    a. Trendelenburg position 15 degree.

6. Position of the surgical team and equipment:
    a. Surgeon on the left, in line with target and monitor, 5 times diagonal length of the screen(co-axial)
    b. Assistant on the right of the surgeon
    c. Sister on the left of the surgeon
    d. Anaesthetist on the usual position, cephalad 

7. Attainment of pneumoperitoneum and introduction of ports
  a. Surgeon makes a stab wound with size 11 blade at the inferior crease of umbilicus
  b. Surgeon check the spring of veress needle as well as patency with saline in 10mm syringe
 c. Surgeon grab entire thickness of the infra-umbilical midline wall of abdomen
 d. Veress needle pointing towards anus, perpendicular to entry point and 45 degrees to the body of patient
 e. Surgeon advances the veress needle and feels 2 clicks (one on rectus sheath and one on peritoneum
 f. Surgeon carry out the injection/aspiration test and saline drop test with a 10mm syringe with saline, to confirm  correct positioning of veress needle
 g. Switch on the insufflator andconnect the tube to veress needle with flow rate of 1L/min. Monitor that the  insufflator is confirming correct positioning of veress needle.
 h. Once pressure reached pre-set pressure, Surgeon uses size 11 blade to make a smiley skin incision in the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port for estimation of incision.
 i. Surgeon insert the telescope and confirms intraperitoneal position.
 j. Surgeon inserts the 5mm ports under direct vision in left iliac fossa.
 k. Inserts atraumatic grasper through 5mm port.

8.  Inspection - inspects the entire abdomen in clockwise direction i.e., caecum, appendix,ascending colon, paracolic gutter, right lobe of liver, gall bladder, falsiform ligament, left lobe of liver, stomach, spleen, descending colon, sigmoid colon,walk through small intestine, pelvis-uterus, fallopian tubes, ovaries, bladder, POD.

9. If any pathology is found, take tissue for biopsy.

10. 5mm port is removed under direct vision  
 
11. The 10mm port is removed together with telescope

12. The 10mm umbilical port facia is closed with vicryl 1-0

17. The 5mm ports, only skin is closed with vicryl 1.0

18. The 10mm port is closed with subcutaneous vicryl 1.0.