safe laparoscopy reducing complications jonathan frappell frcs.frcog
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Safe Laparoscopy Reducing Complications Jonathan Frappell FRCS.FRCOG. Driving without due care and attention. Equipment. Stack system Camera/TV Light source Light lead High speed insufflator - PowerPoint PPT PresentationTRANSCRIPT
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