Editing Laparoscopy


== Physiological impacts of pneumoperitoneum ==

* Cardiovascular
** Bradyarrhythmia - vagal
** Increased MAP, SVR, and CVP
** Decreased CO and SV
** Hypercarbia
* Pulmonary
** Need to increase minute ventilation to compensate for CO2 absorption, which is harder in Trendelenburg
** Reduced pulmonary compliance and FRC
* Regional circulation
** Decreased splanchnic and renal blood flow
** Increased cerebral blood flow
* Positioning
** Head up - venous pooling and hypotension
** Head down - increased preload

== 10mm port (Hasson) ==

* Littlewoods on umbilicus
* Skin incision
* S retractor in
* Put Littlewoods on the cicatrix
* Walk Littlewoods down, separating fat from cicatrix with Metz as I go
* Once junction with linea alba is reached, clear a section and make a cut (1.5cm)
** Ensure on midline - risk of bleeding or entering sheath if off midline
* Stay sutures - one on each side
* Method one:
** Punch through peritoneum with artery, then dilate hole
** If not in, move to method two
** If patient has had previous surgery, shouldn't do this
* Method two:
** Pick up peritoneum between two arteries and divide
** Confirm in peritoneum with an index finger
* Port in, gas on low flow. Pressure of 12mm Hg. Flow of 2-3L/min.
* Camera in, confirm intra-peritoneal
* Gas on high flow
* Patient positioning, depending on procedure.

== Optical entry ==

* Identify Palmer's point (LUQ, mid-clavicular line, 3cm below costal margin - for me, it's generally at tip of left thumb with middle finger on xiphoid process)
* 12mm cut
* 0 degree scope placed into trocar, focus at tip, light on, gas attached
* Gentle downwards pressure and rotation to get down to anterior sheath
* Then will need firmer pressure and big rotations to breach sheath, muscle, posterior sheath
* Continue until intra-abdominal fat is visualised (more lobular), then turn gas on, pull back to visceral surface of peritoneum, and push forwards into the darkness
* Pull out and change to 30 degree scope

== Intracorporeal suturing ==

* Cut suture to 10cm
* Two needle holders
* Load needle forehand in right needle holder
* Place first suture - scooping motion
* Grasp needle with left hand, release right, pull needle through tissue
* Tie knot
*

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== Loss of working space ==

* Inadequate relaxation - tense, flat abdomen with high/normal pressure readings
* Inadequate CO2 - flaccid abdomen - either empty CO2, dislodged insufflator line, or leaks in the system

[[Category:Operating theatre]]