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MHD
Points-Laparoscopy [BPS] Read with GTG

 Components: The laparoscope [0 or 30 angle telescope], insufflator, irrigation/suction system [manyual or

automated].
 Pre-op checks: Palpate for masses & position of aorta. Check varess needle [free folw when open, then
drops to zero+alarm when valve closed. Also check for spring mech, & that it’s sharp]. Check white
balance [a surgical swab 3cm away], & check that diathermy plate in place.
 Position: Lloyed davis. Check that no contact with metals.
 Entery-Closed:
 Check varess [sharp spring loaded outer sheath, blunt inner one with gas channel]. Best one is
small diameter, sharp, disposable.
 Palpate. [masses, aorta].
 Vertical incision at the base of umbilicus. [thinnest part of ant abd wall with peritoneum firmly
adherent, low vascularity, better cosmosis].
 Introducing pneumoperitoneum: Intra-abd pressure rather than amount of gas insufflated is
better indicator for subsequent safe 1ry trocar entery. With 20-25mmHg [≈2L, up to 6], the abd
wall is sufficiently splinted.
o Elevate & stablise skin, hold varess someway down shaft like a pen & direct thrust
vertically through skin, you’ll here 2 clicks [facia &peritoneum] after which change
direction to pelvis & don’t push further. Check correct placement [palmar & pressure].
o Palmar test: Use a syringe filled with NS, connect to varess, pull plunger carefully
[blood? Bowel content?, usually none], then push all fluid [should be no resistance] then
aspirate [none should come, otherwise tip may be in preperitoneum, omentum or
viscus. Here consider alternate site entery].
o Pressure test: with 1L/m flow rate, initial IAP should be <8. Otherwise the pressure will
buildup rapidly & flow will stop.
o DO NOT check correct position by “mobility” of the varess.
 Primary trocar insertion:
o Controlled thrust 90 degree to skin through umbilical incision. Stop once inside cavity.
o Insert laparoscope: 360 degree view. Concern? View by 5mm 2ndry port.
o Type of bowel injuries: type 1 [of normally placed bowl] & 2 [of adherent, abnormally
placed bowel]. Type 2 is predictable from history.
o Bowel adherent to umbilicus may be detected by a carefully performed palmer’s test.
 Entery-Open:
 Transverse sub-umblical [or extend the initial vertical umblical incision 2 cm].
 Grasp facia with forcps & incise vertical or transverse.
 When sheeth is openedstay sutures.
 Open the periton by blunt tip forceps & visualize omentum or bowel, then insert the blunt tip
trocar. Create air-tight seal either by using cone or by using the stay sutures.
 2ndry ports:
 Also with IAP 20-25 mmHg, then reduce to 12-15.
 Inserted either in the relatively avascular midline, or lateral to the epigastric vessels. Suprapubic
approach is often used in female sterilization.
 Avoid superficial & inferior epigastrics by combination of trans-illumination & direct visualization.
 Exit:
 2ndry portstelescope1ry port. When removing 1ry port, open gas valve then pull slowly [to
avoid bowel being sucked in].