Dr.Smita Batni
World Laparoscopy Hospital
FMAS & DMAS, November 2016

1. Surgical team: Gynaecologist as primary surgeon, Anaesthetist, Assistant, Scrub nurse

2. Equipment needed:
a. Laparoscopic tower with insufflator, Light source, HD camera with 30 degree telescope, monitor and bipolar machine.
b. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports
c. Suction and irrigation
d. Basic laparoscopic set with Maryland , atraumatic grasper,  scissors, harmonic,bipolar.
e. Vicryl 0.0  and 3.0 round needle, size 11 blade and BP handle, 10mm syringe with normal saline and sterile dressing 3.

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. Supine position in Trendelenburg position.

6. Position of the surgical team and equipment:
a. Surgeon on the left, distance from the screen is 5 times diagonal length of the screen which is placed opposite and in front of the surgeon.
b. Assistant on the right of the surgeon.
c. Scrub nurse on the left of the surgeon.
d. Anaesthetist in the usual position on the head end.

7. Attainment of pneumoperitoneum and introduction of ports
a. Painting and draping done.
b. Surgeon is to hold the lateral eges of the umbilicus by two allis forceps and then make a stab wound with size 11 blade at the inferior crease of umbilicus.
c. Surgeon should check the spring action of veress needle as well as patency with normal saline in 10mm syringe.
d. Surgeon must grab the entire thickness of the midline infra-umbilical wall of abdomen and assess its thickness and then lift up this part.
e. Veress needle must be held like a dart with gaurding at 4 cm more than assessed thickness of anterior abdominal wall of the patient.It should be pointing towards anus, perpendicular to lifted abdominal wall and 45 degrees to the supra-umbilical abdominal wall.
f. Surgeon must advance the veress needle and feel 2 clicks (one on rectus sheath and one on peritoneum) or give-way sensation.
g. Surgeon then must carry out the injection/aspiration test and saline hanging drop test with a 10mm syringe with normal saline,this is to confirm correct positioning of veress needle.
h. After fully satisfied,the insufflator must be switched on and observe the quadro manometric parameters to monitor that the insufflator is confirming correct positioning of veress needle i.e.intraperitoneal.
i. Once pressure reaches the pre-set pressure, Surgeon must remove the veress needle and use size 11 blade to make a smiling skin incision on the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port on the skin for estimation of incision size.Using an artery forceps the tip should be inserted in this incision and then tip opened to successively dilate the urachus as per the scandinavian technique of primary port placement.
j. Surgeon must insert the 10mm canula with trocar by osccillatory screwing motion, direction being perpendicular till give way sensation is perceived and then change the direction towards the pelvis.Once in, then the trocar is to be removed and telescope inserted and confirm the intraperitoneal placement of this port,only then insufflator should be conneced to it and gas switched on.
k. To begin with an overview inspection of the entire abdomen must be done and duly noted. 
l. Surgeon must then reach out to the target organ (fallopian tube of affected side), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target. 
m. Surgeon must then use the baseball diamond concept to mark the position of the additional 5 mm ports.
n. Surgeon must use trans illumination to avoid any vessel injuries in prospective port sites,after which use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
o. Surgeon should insert both the 5mm ports under direct vision and using principles same as that used for primary port to  avoid inadvertent visceral and vascular injuries.

8. Identification of fallopian tube with ectopic pregnancy in situ:
a. Surgeon should find the affected side fallopian tube by using grasper and a maryland as probes only.The contralateral tube must also be inspected to determine healthy or not.The affected side must be clearly visualized with ectopic complex in  situ.

9. Mesosalpinx
a. With the help of the bipolar and scissors succesively, the meso-salpinx and meso-ovarian are  coagulated and cut, while the left hand holds the fallopian tube with an atraumatic grasper.
b. While coagulating and cutting direction must be from lateral to medial and care must be taken to stay close to the tube and stop about 6 mm lateral to the tubo-cornual junction.

10. Insure haemostasis
a. After the tube is removed the area operated upon must be visualized for perfect haemostasis,if needed bipolar can be used to coagulate mesosalpinx.

11. Tissue retrieval-Removed fallopian tube with ectopic in situ
a. It can be delivered by grabbing the cut end with maryland forceps through 10mm port on the umbilicus, under vision with the 5mm telescope in the lateral port.

12. The two 5mm ports should be removed under direct vision and port sites must be inspected for bleeding if any.

13. The 10mm umbilical port fascia must be closed using a veress needle as a suture passer(Suture used  is vicryl 0.0).Before tying the suture the port is to be removed together with the telescope and all gas let out.

14. The 10mm port is closed with subcutaneous vicryl 3.0 on a cutting needle.

15. The 5mm ports only skin is closed with vicryl 3.0.

16. Occlusive aseptic sterile dressing is applied on all 3 skin wounds.

17.  Patient monitored till comes out of general anaesthesia and post op vitals and operative findings must be duly noted in patient case sheet.Tissue retrieved must be sent for histopathological examination and patient once stable must be shifted to post op care area for further management.Attendants must be informed of the same and counselled appropriately.