safe laparoscopy reducing complications jonathan frappell frcs.frcog
TRANSCRIPT
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Safe LaparoscopyReducing Complications
Jonathan Frappell FRCS.FRCOG.
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Driving without due care and attention
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Equipment
• Stack system Camera/TV Light source Light lead High speed insufflator Video/Still recorder
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Equipment
• Grasping forceps Johannes Manhes• Scissors• Diathermy monopolar/bipolar• Suction/irrigation 5/ 10cms
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Consent
Risk of serious complication requiring LAPAROTOMY
3-5 per 1000 3 per 1000 intestinal injury
1 per 1000 vascular injury
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Safe Entry
• RCOG Greentop Guideline No.48(Oct.2007)• SratOG Module 2 Perioperative care in gynaecology
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Safe entry
• Primary trocar Veress needle technique Hasson open entry Alternative entry site “Safety” trocars optical Ternamian screw ‘Step’ system
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Safe Entry
• Veress needle Patient flat Sharp Intra-umbilical vertical incision Tests of correct placement Maximum of two attempts Insufflate to 25mmHg
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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
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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
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Safe Entry
• After insertion of primary trocar Reduce pressure to 15mmHg Visual check Head down tilt• Secondary trocars inserted under direct vision
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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
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Electrical Energy• Bipolar Current flows only between tips of
the forceps “blades” Excellent for haemostasis No risk of stray current damage
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Electrical Energy
• Monopolar Risk of stray current Cutting current has lower voltage than coagulating current
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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
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Port Closure
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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”
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Thank You