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Safe Laparoscopic Surgery - Erc-rcog.pptx

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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
            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 Attributes
              of 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

				
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posted:3/20/2014
language:English
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