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
Obese
Hasson
Optical ports
b)Alternative entry site
Palmer’s point
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