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

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