Dr Tran Tuyet Thi NGUYEN
Gynaecology – DMAS

1. Preoperative check of consent form and patient past medical history
2. Ensure patient is fasted and has seen the anaesthetist
3. Review images and relevant bloods to ensure no suspicion for malignancy
4. Check pregnancy status by urinary HCG
5. Perform surgical safety checklist    
6. Give 2 grams IV cephazolin and 500mg IV metronidazole pre-incision
7. General anaesthesia
8. Diathermy pad on patient
9. Palpate abdomen    
10. TED stockings and pneumatic calf compressors applied
11. Ensure patient is adequately shaved in case of suprapubic port
12. Patient is placed in Lloyd Davies position
13. Chlorhexidine prep of abdomen    
14. Surgeon and assistant to scrub    
15. Aseptic gown and glove up
16. Betadine prep of the vagina and vulva
17. Surgical drapes applied
18. Adjust operating table at 0.49% of surgeon’s height
19. 14F indwelling urinary catheter inserted
20. Abdominal, bimanual, and speculum examinations
21. Sims speculum into posterior fornix
22. Tenaculum at 12 o’clock of cervix  for traction
23. Sound the uterus
24. Connect appropriate tip to Valtchev uterine manipulator    
25. Insert Valtchev manipulator into uterine cavity
26. Change sterile gloves
27. Position monitors, target organ, and surgeon in coaxial alignment
28. Monitor should be 15 degrees lower than surgeon’s vision
29. Surgeon positioned on left and assistant on right
30. Ensure insufflator and whole stack is visible to surgeon
31. Turn on insufflator and choose ‘high flow’ option    
32. Connect light source and 10mm 30-degree telescope
33. Turn on camera, focus at 10cm, white balance, then standby
34. Set up Harmonic scalpel and Ligasure with cord placed separately to telescope
35. Arrange suction tubing, smoke evacuator, lens cleaner, and graspers (Maryland grasper, atraumatic bowel    
grasper, laparoscopic Tenaculum)
36. Set pressure at 15mmHg and flow rate 1L/min on Veress setting
37. Connect suction tubing and CO2 gas tubing    
38. Check  Veress needle spring and patency
39. Connect Veress needle to CO2 tubing and flush out dead space
40. Take 2 Allis forceps to evert and hold each side of umbilicus
41. Use number 11 blade to place small horizontal stab wound to inferior crease of umbilicus
42. Mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath    
43. Measure abdominal wall thickness and add 4cm for distance to hold Veress needle
44. Hold Veress needle at calculated length like a dart
45. Assistant and surgeon to hold the lower abdomen up
46. Surgeon to place Veress needle in sub-umbilical incision at 45 degrees down into pelvis towards anus and also
perpendicular to abdominal wall
47. Insert Veress needle until two clicks seen
48. Maintain 45-degree angle of the Veress
Task analysis of total laparoscopic hysterectomy for benign pathology
Dr Tran Tuyet Thi Nguyen
Page 2
49. Confirm correct Veress needle placement –irrigation test, aspiration test, plunger test, and hanging drop test
50. Connect CO2 gas tube to Veress needle
51. Turn on CO2 and allow flow rate of 1L/min
52. Observe quadro-manometric indicators to rise in parallel for volume of gas and actual pressure
53. Observe for general distension of abdomen
54. Palpate for loss of liver border
55. Once pneumoperitoneum is achieved with set pressure of 20mmHg,extend skin incision horizontally to 11mm
56. Kelly’s clamp to dissect subcutaneous adipose away from rectus sheath
57. Hold 10mm port like a gun
58. Insert 10mm port perpendicular to abdomen & tilt to 60 degrees towards pelvis when there is loss of resistance
59. Confirm intra-abdominal placement of primary port with whooshing sound and audible click
60. Take out trocar    
61. Set the pressure rate at 10L/min
62. Apply gas tubing to primary port
63. Insert telescope and inspect entry point
64. Request for Trendelenburg of 15-30 degrees
65. Assistant to hold light source and lead with thumb and index finger on right side of patient
66. Camera cable should be at 6 o’clock and light source should be at 12 o’clock
67. Apply baseball diamond shape principle for lateral port insertion
68. Transilluminate at target organ, which are bilateral uterine arteries
69. Make a diamond shape with thumbs at umbilicus and index fingers towards target organ
70. Incise skin along Langer lines for secondary ports x3
71. Insert lateral ports (5mm x2 at LIF and RIF) at position of snuff box which is about 8cm from umbilicus    
72. Insert 10mm port at 5cm above suprapubic
73. All ports should be inserted perpendicular to the abdomen
74. Once all lateral ports inserted, then reduce set pressure to 12mmHg
75. Atraumatic graspers to perform systematic inspection of entire abdomen and pelvis in clockwise fashion
76. Surgical assistant to antevert uterus
77. Identify bilateral ureters and mark the overlying peritoneum near uterosacral ligaments with harmonic scalpel
78. Stretch the uterus to anterior and contralateral to surgical site for traction    
79. Identify bilateral round ligaments–Ligasure to coagulate round ligaments 4 cm away from uterus
80. Harmonic scalpel to transect bilateral round ligaments
81. Harmonic scalpel to dissect anterior leaf of broad ligaments bilaterally toward uterovesical fold
82. Harmonic scalpel to dissect urinary bladder away from UV fold to the level of vagina
83. Harmonic scalpel to coagulate and transect bilateral fallopian tubes  and ovarian ligaments 6mm from uterus
84. Skeletonise along uterus and bilateral uterine arteries with Harmonic scalpel
85. Ligasure to coagulate bilateral uterine arteries
86. Harmonic scalpel to transect uterine arteries adjacent to uterus
87. Harmonic scalpel to coagulate and transect cervical part of bilateral uterosacral ligaments (USL)
88. Harmonic scalpel to coagulate and transect bilateral cardinal ligaments
89. Ensure good vision with smoke evacuator and lens cleaner    
90. Harmonic scalpel to perform colpotomy at level of external os–retrovert uterus to start from anterior aspect    
then stretch uterus to contralateral side for traction to continue colpotomy on each side
91. Insert laparoscopic tenaculum into suprapubic port to grasp fundus    
92. Manipulate uterus upwards    
93. Harmonic scalpel in LIF port to complete posterior colpotomy at level of cervical USL
94. Once colpotomy completed, cervix to be aligned over vault in preparation of uterus removal
95. Remove Valtchev device, then use sims speculum and vulsellum forcep from PV to grasp cervix
96. Place wet pack over vagina to maintain pneumoperitoneum
97. Change gloves and return to laparoscopy
98. Insert 1 vicryl suture with endo-ski needle through suprapubic port
99. Suture full thickness of vault using 90cm long 1 vicryl suture with extracorporeal Mishra knot and Bandharkar knot    pusher    for vault closure ulous detail to watch needle entry and exit from abdominal cavity
101. Close vault angles first then remaining of vault by interrupted sutures
102. Check for haemostasis
103. Check for ureteric peristalsis
104. Normal saline lavage, then suction of fluid and blood
105. Ligasure for haemostasis
106. Once haemostasis achieved, release gas and remove instruments, but leave ports in situ
107. Remove IDC
108. Insert lubricated 4mm cystoscope through urethra
109. Inject 300ml of normal saline into bladder without pressure via a giving set
110. Then turn clamp off    
111. Check for bladder integrity and good bilateral ureteric jets
112. Once completed cystoscopy, re-insert IDC
113. Re-start CO2 for pneumoperitoneum to confirm haemostasis again
114. Ensure instrument and swab count correct
115. Close rectus sheath of suprapubic port under vision by using Veress needle technique with 1 vicryl
116. Remove suprapubic port and use surgical knot (2-1-1) to close the rectus sheath
117. Remove remaining two lateral ports under vision
118. Flatten patient
119. Release pneumoperitoneum
120. Leave telescope in but turn off camera    
121. Remove sub-umbilical port
122. Remove telescope
123. Close skin of all four stab wounds with 3-0 monocryl subcuticular sutures
124. Local anaesthetic infiltration to all port incisions    
125. Apply dressings to each wound
126. Remove drapes
127. Send specimen in formalin for histopathology analysis