practicle problems 002
TRANSCRIPT
PRACTICAL PROBLEMS INPRACTICAL PROBLEMS INLAPAROSCOPYLAPAROSCOPY
By Dr. RAMESH .BBy Dr. RAMESH .B
Anesthesia Problems
Equipment Problems
Electro Surgery Problems
Expertise Problems
Cost Problems
Inadequate Team
Antagonism
Inexperienced Assistant
Problems of Disposing
Disposables
Power Supply Problems
OR Setup Problems
Practical Problems
IntroductionIntroduction
Operative laparoscopy is an evolving field and Operative laparoscopy is an evolving field and
surgeons are new to this field and are still in the surgeons are new to this field and are still in the
process of acquiring and polishing their surgical process of acquiring and polishing their surgical
skills. Anything new poses challenging problems skills. Anything new poses challenging problems
and only time and experience can help one and only time and experience can help one
overcome them.overcome them.
OR Set Up
Equipment Problems
Laparoscopic Laparoscopic EquipmentEquipment
1.1. Assure table tilt Assure table tilt
mechanism is functional.mechanism is functional.
2.2. Consider using shoulder Consider using shoulder
brace and extra safety brace and extra safety
strap.strap.
3.3. Assure availability of Assure availability of
Foley catheter and N/G Foley catheter and N/G
tube.tube.
Preoperative Preoperative ConsiderationsConsiderations
4.4. Assure all power sources are Assure all power sources are connected and appropriate connected and appropriate units are switched "on" units are switched "on" (Don’t use multi-socket (Don’t use multi-socket single source or the circuit single source or the circuit will overload).will overload).
5.5. Assure adequate volume of Assure adequate volume of compressed gas (at compressed gas (at insufflator and pressure insufflator and pressure irrigator). Backup full tank irrigator). Backup full tank must be available.must be available.
6.6. Assure insufflator Assure insufflator alarm is set alarm is set appropriately. appropriately. Assure tight Assure tight connection between connection between insufflator tubing insufflator tubing and Luer-lock and Luer-lock adapter.adapter.
7.7. Assure full volume Assure full volume in irrigation fluid in irrigation fluid container (recheck container (recheck during case).during case).
8.8. Check the electrosurgical Check the electrosurgical unit; make sure auditory unit; make sure auditory alarm of machine is alarm of machine is functioning properly and functioning properly and the grounding pad is the grounding pad is appropriate for the appropriate for the patient.patient.
9.9. Check Veress needle for Check Veress needle for proper plunger/spring proper plunger/spring action and assure easy action and assure easy flushing through flushing through stopcock and/or needle stopcock and/or needle channel.channel.
10.10. Assure closed stopcocks Assure closed stopcocks on all ports.on all ports.
Excessive PressureRequired for Insufflations
Veress Veress needle or needle or cannula tip cannula tip not in free not in free peritoneal peritoneal cavitycavity
Reinsert Reinsert needle or needle or cannulacannula
Veress is inside, Veress is inside, but gas is not but gas is not flowing and flowing and pressure is high-pressure is high-
may be a piece of may be a piece of omentum is stuck –omentum is stuck –shake the shake the abdominal wall and abdominal wall and withdraw the withdraw the needleneedle
maybe the Veress is maybe the Veress is not patent- flush it not patent- flush it with saline to clear with saline to clear the channel.the channel.
Occlusion of Occlusion of tubing tubing (kinking, table (kinking, table joints, etc.)joints, etc.)
Port stopcock Port stopcock turned offturned off
Patient is Patient is “light”“light”
Inspect full Inspect full length of tubing. length of tubing. Replace with Replace with proper size as proper size as necessarynecessary
Fully open Fully open stopcockstopcock
Give more Give more muscle relaxantmuscle relaxant
Loss of Loss of PneumoperitoneuPneumoperitoneu
mm CO2 tank emptyCO2 tank empty
Accessory port Accessory port stopcock(s) notstopcock(s) not
properly properly adjustedadjusted
Leak in sealing Leak in sealing cap or stopcockcap or stopcock
Excessive Excessive suctioningsuctioning
Change tankChange tank
Inspect all Inspect all accessory accessory ports. Open ports. Open or close or close stopcock(s) stopcock(s) as neededas needed
Change cap Change cap or cannulaor cannula
Allow time to Allow time to reinsufflatereinsufflate
Tighten Tighten connectionsconnections
Replace or Replace or secure secure suturessutures
Connect Connect tubingtubing
Adjust Adjust flow rateflow rate
Loose connection Loose connection of insufflator of insufflator tubing at source tubing at source or at portor at port
Hasson stay Hasson stay sutures loosesutures loose
Tubing Tubing disconnection disconnection from insufflatorfrom insufflator
Flow rate set too Flow rate set too lowlow
EntryEntry 2)- Trocar- if 2)- Trocar- if
the the pneumoperitonpneumoperitoneum is lost eum is lost prior to prior to insertion due to insertion due to a deep incision-a deep incision-
Close the site Close the site with Allis, with Allis, create create pneumoperitonpneumoperitoneum from a eum from a different point, different point, preferably preferably Palmar’s and Palmar’s and introduce introduce trocar from the trocar from the primary site.primary site.
3)-Frequent 3)-Frequent slipping of 5mm slipping of 5mm trocars -trocars -
use a threaded use a threaded cannulacannula
If If extraperitoneal extraperitoneal insufflation insufflation occurs, occurs,
EntryEntry
let the gas escape let the gas escape and gain entry from and gain entry from the Palmar’ s point the Palmar’ s point which is a safe which is a safe alternative. This alternative. This point of insertion is point of insertion is also safe in a also safe in a patient with patient with multiple abdominal multiple abdominal incisions incisions
PositionPosition Position yourself well and the table must be at Position yourself well and the table must be at
the level of your elbow to ease the strain on the level of your elbow to ease the strain on the shoulder muscles.the shoulder muscles.
Position the patient well for vaginal Position the patient well for vaginal manipulation and free range of movements.manipulation and free range of movements.
VisionVision
1)Halogen lamp 1)Halogen lamp gives a yellow gives a yellow hue-hue-
2) Hazy picture-–2) Hazy picture-–to prevent a to prevent a hazy picturehazy picture
3) frequent 3) frequent foggingfogging
get used to it or get used to it or switch over to Xenonswitch over to Xenon
Focus your scope Focus your scope prior to entry prior to entry and properly and properly clean the lens clean the lens and the camera and the camera headheadfogging-clean fogging-clean the tip with the tip with Betadine / hot Betadine / hot salinesaline..
VisionVision 4)If the blood and 4)If the blood and
debris are debris are persistently persistently irritatingirritating
TIP-3 chip digital TIP-3 chip digital camera gives a camera gives a very good vision very good vision and a smooth and a smooth picture. A medical picture. A medical monitor prevents monitor prevents eye straineye strain
Flush the Flush the primary trocar primary trocar to clear any to clear any trickling blood trickling blood from the from the insertion site insertion site and then and then touch the tip touch the tip of the of the laparoscope laparoscope with irrigating with irrigating fluid on a fluid on a clean surfaceclean surface
Loose Loose connection at connection at source or source or scopescope
Bulb is burned Bulb is burned outout
Fiber optics Fiber optics are damagedare damaged
Adjust Adjust connectorconnector
Replace Replace bulbbulb
Replace Replace light cablelight cable
VisionVision Automatic iris Automatic iris
adjusting to adjusting to bright bright reflection from reflection from instrumentinstrument
Monitor Monitor brightness brightness turned downturned down
Room Room brightness brightness floods monitorsfloods monitors
Re-position Re-position instrumentsinstruments, ,
Readjust Readjust settingsetting
Dim room Dim room lightslights
Camera Camera control or control or other other components components (V.C.R., (V.C.R., printer, light printer, light source, source, monitor) not monitor) not “on”“on”
Cable Cable connector connector between between camera control camera control unit and/or unit and/or monitors not monitors not attached attached properlyproperly
Make sure all Make sure all power sources power sources are plugged in are plugged in and turned onand turned on
Cable should Cable should run from “video run from “video out” on camera out” on camera control unit to control unit to “video in” on “video in” on primary primary monitor. Use monitor. Use compatible compatible cables for cables for camera unit and camera unit and light source.light source.
VISIONVISION
foggingfogging Condensation on lens from cold Condensation on lens from cold scope on entering warm scope on entering warm abdomenabdomen
Wipe lens on viscera with Wipe lens on viscera with warm salinewarm saline
Cold gas Cold gas Use ThermoflatorsUse Thermoflators
Condensation on scope Condensation on scope eyepiece, camera lenseyepiece, camera lens
Detach camera from scope Detach camera from scope and clean lensand clean lens
Flickering, Flickering, electrical electrical interferenceinterference
Moisture in camera cable Moisture in camera cable connecting plugconnecting plug
Poor cable sheildingPoor cable sheilding
Insecure connection of video Insecure connection of video cable b/n monitorscable b/n monitors
Use suction or compressed Use suction or compressed air to dry out moistureair to dry out moisture
Replace cables as necessary Replace cables as necessary and move ESU away from and move ESU away from video equipmentvideo equipment
Reattach video cable at each Reattach video cable at each monitormonitor
Blurring, Blurring, distortiondistortion
Incorrect focusIncorrect focus
Cracked lens, internal moistureCracked lens, internal moisture
Too grainyToo grainy
Focus the cameraFocus the camera
Inspect scope/camera sos Inspect scope/camera sos replacereplace
Adjust enhancements or Adjust enhancements or grain settings grain settings
Suction / IrrigationSuction / Irrigation
Occlusion of Occlusion of tubing tubing (kinking, (kinking, blood clot, blood clot, etc.)etc.)
Occlusion of Occlusion of valves in valves in suction/irrigasuction/irrigator devicetor device
Inspect full Inspect full length of tubing. length of tubing. If necessary, If necessary, detach from detach from instrument and instrument and flush tubing with flush tubing with sterile salinesterile saline
Detach tubing, Detach tubing, flush device with flush device with sterile salinesterile saline
Suction / IrrigationSuction / Irrigation
Not attached to Not attached to wall wall suction/machinsuction/machinee
Irrigation fluid Irrigation fluid container not container not pressurizedpressurized
Inspect and secure Inspect and secure suction & wall suction & wall source connectorsource connector
Inspect compressed Inspect compressed gas source, gas source, connector, pressure connector, pressure dial settingdial setting
Expertise Expertise ProblemsProblems
HAND EYE HAND EYE COORDINATIONCOORDINATION Surgeon must develop good hand Surgeon must develop good hand
eye coordination before eye coordination before attempting any laparoscopic attempting any laparoscopic surgery by constant practice on surgery by constant practice on the pelvi Trainer.the pelvi Trainer.
Camera HoldingCamera Holding Assistant should stand on the Rt Assistant should stand on the Rt
side of the Patient and be an side of the Patient and be an expert at holding the camera & expert at holding the camera & must anticipate the next steps of must anticipate the next steps of the surgery helping the smooth the surgery helping the smooth progression.progression.
Operative Operative Techniques-Techniques-
Large Uteri-Large Uteri- Position the primary and Position the primary and
lateral ports higher.lateral ports higher.
Use your ports efficiently Use your ports efficiently along with a good vaginal along with a good vaginal manipulator with patient’s manipulator with patient’s buttocks protruding buttocks protruding beyond the edge of the beyond the edge of the table to give traction table to give traction counter traction to make counter traction to make the structures more taut the structures more taut so that cauterization and so that cauterization and dissection or cutting dissection or cutting becomes easy. becomes easy.
Myoma screw is very Myoma screw is very helpful for traction.helpful for traction.
Creation Of Creation Of PlanesPlanes
While pushing the UV While pushing the UV fold-fold-
try coming from the lateral try coming from the lateral edges towards the centreedges towards the centre
If you still don’t happen to get If you still don’t happen to get the plane- convert TLH to the plane- convert TLH to LAVHLAVH
In Adhesiolysis –In Adhesiolysis – Always start from the normal Always start from the normal
anatomy and proceed towads anatomy and proceed towads the abnormal as the planes the abnormal as the planes open up.open up.
Use harmonic as the Use harmonic as the cavitational effect will help cavitational effect will help the creation of planes.the creation of planes.
Operative Operative Techniques-Techniques-
Intra operative bleeding-Intra operative bleeding- Always cut less and cauterize more Always cut less and cauterize more If at all bleeding occurs- first see-don If at all bleeding occurs- first see-don
t comprise on vision-by repeated t comprise on vision-by repeated suction irrigation-isolate the bleeder suction irrigation-isolate the bleeder and coagulateand coagulate
Tissue RetrievelTissue Retrievel
CLOTS in Ectopic CLOTS in Ectopic pregnancypregnancy
Spoon forcepsSpoon forceps High pressure irrigation and High pressure irrigation and
suctionsuction 10mm suction cannula10mm suction cannula ColpotomyColpotomy EndobagEndobag
Tissue RetrievelTissue Retrievel Removal of Removal of
degenerated degenerated fibroids like cystic fibroids like cystic , calcified fibroids , calcified fibroids are difficult toare difficult to morcellatemorcellate
colpotomy colpotomy is a better is a better optionoption..
If the myoma If the myoma screw breaks screw breaks during the during the enucleation of the enucleation of the fibroid. fibroid.
- - remove the broken remove the broken piece as it may piece as it may damage the damage the morcellator blade if it morcellator blade if it touches the blade touches the blade during morcellationduring morcellation
Loss of Loss of Pneumoperitoneum after Pneumoperitoneum after
ColpotomyColpotomy Use uterus as a Use uterus as a
pneumo occluderpneumo occluder Ceanna Glove- Ceanna Glove-
wet sponge in a wet sponge in a glove as a glove as a pneumo pneumo occluder.occluder.
Various Various manipulators manipulators with inbuilt with inbuilt pneumo-pneumo-occluders.occluders.
EndosuturingEndosuturing
Practice makes Practice makes one perfectone perfect
Use short length Use short length of suture of suture materialmaterial
Electro Surgical Electro Surgical UnitsUnits
Patient not Patient not grounded grounded properlyproperly
Connection Connection between between electro-electro-surgical unit surgical unit and instrument and instrument looseloose
Foot pedal or Foot pedal or hand switch hand switch not connected not connected to to electrosurgical electrosurgical unitunit
Assure Assure adequate adequate return return pad pad contactcontact
Inspect Inspect both both connectinconnecting pointsg points
Make Make connectioconnectionn
ELECTRO-SURGICAL UNITELECTRO-SURGICAL UNIT
Wrong output Wrong output selectedselected
Connected to Connected to the wrong the wrong socket on the socket on the electrosurgical electrosurgical unitunit
Instrument Instrument insulation insulation failure outside failure outside of surgeon’s of surgeon’s viewview
Correct output Correct output choicechoice
Check that Check that cable is cable is attached to attached to proper socketproper socket
Use new Use new instrument and instrument and inspect inspect insulationinsulation
Electrosurgical Electrosurgical UnitUnit
Cautery Cautery smoke smoke obscures obscures visionvision
If Bipolar If Bipolar is not is not working, working,
-do suction and -do suction and remove the remove the smoke, instead smoke, instead of opening the of opening the vent of the vent of the trocar as it will trocar as it will prevent prevent inhalationinhalation
for coagulation for coagulation use monopolar use monopolar thermocoagulatithermocoagulationon
Electro Surgical Electro Surgical UnitUnit
Lateral spread-use harmonic when Lateral spread-use harmonic when close to vital structures or sharp close to vital structures or sharp dissection with scissorsdissection with scissors
Use bipolar whenever appropriateUse bipolar whenever appropriate Coagulate with cutting current as it Coagulate with cutting current as it
is low voltageis low voltage
Antagonism From Antagonism From Fellow Fellow
GynaecologistsGynaecologists
N2O causes bowel distention- N2O causes bowel distention- switch to mixture of O2 and Airswitch to mixture of O2 and Air
Switch over to sevoflurane for Switch over to sevoflurane for smooth recoverysmooth recovery
Problems Caused Problems Caused by Anaesthetiaby Anaesthetia
Financial ProblemsFinancial Problems
Costly equipmentsCostly equipments TackersTackers MeshMesh
CONCLUSIONCONCLUSION
Patience and persistence can help you Patience and persistence can help you master the laparoscopic surgical master the laparoscopic surgical technique. Efficiency increases with technique. Efficiency increases with experience and remember it is a team experience and remember it is a team effort and first build a good ground effort and first build a good ground support team and train them well.support team and train them well.
THANK U FOR A PATIENT THANK U FOR A PATIENT HEARINGHEARING