safe laparoscopy reducing complications jonathan frappell frcs.frcog

Safe LaparoscopyReducing Complications

Jonathan Frappell FRCS.FRCOG.

Driving without due care and attention

Equipment

• Stack system Camera/TV Light source Light lead High speed insufflator Video/Still recorder

Equipment

• Grasping forceps Johannes Manhes• Scissors• Diathermy monopolar/bipolar• Suction/irrigation 5/ 10cms

Consent

Risk of serious complication requiring LAPAROTOMY

3-5 per 1000 3 per 1000 intestinal injury

1 per 1000 vascular injury

Safe Entry

• RCOG Greentop Guideline No.48(Oct.2007)• SratOG Module 2 Perioperative care in gynaecology

Safe entry

• Primary trocar Veress needle technique Hasson open entry Alternative entry site “Safety” trocars optical Ternamian screw ‘Step’ system

Safe Entry

• Veress needle Patient flat Sharp Intra-umbilical vertical incision Tests of correct placement Maximum of two attempts Insufflate to 25mmHg

Safe Entry

HIGH RISK Patients

Very thin Hasson open entry

Previous Laparotomy Avoid scars Consider a)Hasson entry

b)Alternative entry site Palmer’s point Obese Hasson

Optical ports

Major Vascular Injury

• Immediate Midine Laparotomy Apply pressure• Call for help Surgical/Anaesthetic• O Neg Blood• X match 6 units/FFP

• Written protocol in theatre

Safe Entry

• After insertion of primary trocar Reduce pressure to 15mmHg Visual check Head down tilt• Secondary trocars inserted under direct vision

Electrical Energy

• Check for insulation defects• Actvate only when forceps in contact with

tissue• Use lowest effective current setting• Instrument tip and tissue gets HOT

Electrical Energy• Bipolar Current flows only between tips of

the forceps “blades” Excellent for haemostasis No risk of stray current damage

Electrical Energy

• Monopolar Risk of stray current Cutting current has lower voltage than coagulating current

Post-op Recovery

• Suspect bowel damage if condition deteriorates 24-48 hrs post-op

• <50% bowel injuries recognised at time of op.• Av.time to diagnosis 1.7 days

Delay can be fatal

Port Closure

Fundamental Attributesof a Safe Surgeon

• Communication• Decision making• Judgment• Leadership

“the strength of simulation is as an adjunct rather than as an alternative to clinical experience”

Thank You