LAPAROSCOPIC CHOLECYSTECTOMY
GRADE 6 (EXTREMELY SEVERE)
Theatre Equipment and Material
Equipment Checks
Insufflator Checks
Diathermy Checks
Patient Checks
Anaesthesia
Veress Needle
Grasp on Lower Abdomen
Umbilical Port Insertion
Umbilical Camera Insertion
Check for damage by Needle or Trocar
Epigastric Operating Port Insertion
Adhesion Division
Abdominal Contents Inspection
Identification of Anatomy
Dissection of Cystic Duct and Artery
Cystic Duct Clipping
Cystic Artery Clipping
Cystic Duct Cutting
Gallbladder Dissection
Drainage
Gallbladder Removal
Removal of forceps
Closure
Index
THESE STEPS COVER
LAPAROSCOPIC CHOLECYSTECTOMY
THESE STEPS DO NOT COVER
LAPAROSCOPIC CHOLANGIOGRAM
LAPAROSCOPIC CHOLEDOCHOSCOPY
LAPAROSCOPIC REMOVAL OF COMMON BILE DUCT STONES
0 LAPAROSCOPIC CHOLECYSTECTOMY THEATRE LAYOUT - PROCEDURE STEPS Top
1 NON-SURGICAL EQUIPMENT LIST
2 VIDEO SYSTEM (WOLF)
2190.20 Video Trolley with isolation transformer
5370.01 CCD Video Camera complete with Control Unit
5261.27 27mm Lens
5370.52 20" Sony Monitor
3 VIDEO RECORDER
5631.01 Sony U-matic Recorder VO 7630
4 LIGHT SOURCE
5108.01 Auto Iris High Power Light Source
5 CABLES
815.009 High Frequency connecting Cable for electrodes and probes
8106.009 High Frequency connecting cables for forceps
6 INSUFFLATION SYSTEM
2154.75 High Flow insufflator with recirculating Smoke Filter System including sterile filters.
7 SPARES
Sterile filters for insufflator.
CO2 Cylinder
Spare light bulb
Spare fuses
8 STANDARD STERILE SURGICAL EQUIPMENT (FRIARAGE
HOSPITAL)
1 X MINOR PACK
3 X Sponge holders
2 X Gallipots
1 X Medium receiver
2 X Small receiver
1 X Medium bowl
2 X Large water bowls
1 X NO 3 Knife handle
1 X 15 Swann Morton blade
2 X Littlewoods forceps
4 X Curved Jolls for forceps
2 X Roberts forceps
1 X Grooved hernia director
1 X 5" Straight scissors
1 X McIndoes scissors
2 X Small Langenbeck retractors
2 X Large Langenbeck retractors
1 X Heavy non-toothed forceps
1 X 2ml Syringe for ultrastop
1 X 2O Ml syringe for 20ml 0.25% Bupivacaine
1 X Green 21 SWG needle for Bupivacaine
1 X Small needle holder
1 X Diathermy sheath
1 X Suction tubing
1 X Irrigation tubing
1 X Giving set
1 X Plastic sheath for camera lead and sterile adhesive strip
1 X Poole sucker
8 X Towel clips
0 X Cotton buds
2 X Fine diathermy leads
1 X Insufflation tubing
1 X Packet suture strips
1 X Veress needle
9 STANDARD STERILE SURGICAL EQUIPMENT (DARLINGTON MEMORIAL HOSPITAL)
1 X General set
1 X Laparoscopy set
1 X General set extras
2 X Sucker tubing
1 X Complete diathermy set
1 X Cystoscopy irrigation set with 500ml saline
1 X Heavy non-toothed forceps
1 X Veress needle
1 X Number 15 Swann-Morton blade
2 X Small Langenbeck retractor
1 X Volsellum forceps
1 X Plastic sheath for camera lead and sterile adhesive strip
10 X Cotton wool buds
1 X Laurence needle holder
1 X Bowl
1 X Receiver
1 X 2ml syringe for ultrastop
1 X 2ml syringe for saline
1 X 20ml syringe for Bupivacaine
1 X 21 SWG Green top needle
4 X Extra towel clips
10 STANDARD STERILE SURGICAL EQUIPMENT (ST JOHN OF GOD HOSPITAL)
11 SPECIAL STERILE SURGICAL EQUIPMENT
12 TELESCOPES
8934.441 Panoview telescope 0 10mm diameter
8061.455 Light transmitting cable 2.4 m long
13 TROCARS AND SLEEVES
2 X 8934.01 10mm trocar sleeve with piston valve
8934.12 10mm trocar with pyramid tip
8934.981 Reducing sleeve 10mm - 5 mm
2 X 8940.01 5mm trocar sleeve with piston valve
8940.12 5MM. Trocar with pyramid tip
14 VERESS NEEDLE
2 X 8302.12 Veress needle
15 FORCEPS, SCISSORS AND CLIP APPLIERS
8385.10 Grasping forceps with large teeth 10mm (The Rotweilers)
2 X 8383.08 Grasping forceps with alligator teeth with lock (The Alligator)
8383.141 Atraumatic grasping forceps 5mm flat (The Racquets)
2 X 8383.45 Hooked scissors 5mm
16 SUCTION/IRRIGATION PROBES
8383.732 Suction and irrigation probe 5mm
17 ELECTRODES 2 X 8383.421 HOOK ELECTRODES 5mm.
18 MISCELLANEOUS
815.009 High frequency connecting cab le for electrodes and probes
8106.009 High frequency connecting cable for forceps
89.08 10mm sealing caps per 10
89.02 5mm sealing caps per 10
88.02 Sealing caps for forceps per 10
8383.78 Introducer for ethibinders/endoloops
Suture introducer
19 SURGICAL DISPOSABLES
171025 Surgiport disposable trocar 10 mm 50.00
176615 Endoclip disposable applier 110.00
?175006 Surgiport converter 5.5mm 5.00
20 SURGICAL DISPOSABLE SPARES
178009 Endoclip 10ml accessory kit 286.00
1 Endoclip ml disposable applier with medium-large titanium clips
1 Surgiport 10mm trocar with 1 stainless sleeve, 1 radiolucent sleeve
1 Surgipost 5mm trocar with 1 stainless sleeve, 1 radiolucent sleeve
1 Surgineedle 120mm instrument
2 Surgigrip 5mm disposable sleeves
1 Surgigrip 10mm disposable sleeve
3 Surgiport converters 3.5mm, 4.5mm, 5.5mm
Endo-shears disposable scissors
Endoloop sutures
2 X EH495G Chromic catgut 1 69.00
10mm disposable seal
5mm disposable seal
21 THEATRE FURNITURE
1 X Large trolley
1 X Small trolley
1 X Drip stand
1 X Pressure infusor
22 MATERIALS
Arterial sloop
Fascia closure Number 1 Vicryl (Ethicon W9251)
Suture strips
Skin spray nobecutaine
Skin dressing Mepore
Bacteriology swab
23 PHARMACEUTICALS
Cefuroxime 750mg IV
Irrigation saline 500ml 0.9% No heparin
Skin injection Bupivacaine 20ml 0.5%
Diclofenac suppository
24 ASSORTED EXTRAS AND ITEMS FOR FUTURE PURCHASE
20" Sony monitor
Unicol monitor stand for 2nd Monitor
8385.13 Grasping and extracting forceps 10mm (No lock).
8389.801 Clip applicator for Ethicon TI 300 Clips
8383.022 Scissors insulated
28378 C Rimmer Olsen cholangiocatheter guided grasper
3mm Needle holder for internal sutures
5MM. Needle holder for internal sutures
25 ?
EQUIPMENT CHECKS Top
26 VIDEO CAMERA CHECKS
27 PLUG IN AT THE WALL
28 PLUG IN AT MULTISOCKET BOARD
29 PLUG POWER LEAD INTO THE BACK OF THE ENDOCAM CONTROLLER UNIT
30 SWITCH ON AT THE WALL
31 PREPARE THE CAMERA
Choose the oblique viewing camera which is in the bottom drawer of the video stand.
Remove the cover from the camera lens by squeezing the 2 spokes on the camera.
Push fit the camera lead onto the camera.
32 PLUG THE CAMERA LEAD INTO THE FRONT OF THE CONTROLLER
The lead will plug in 1 way only.
33 SWITCH ON THE CAMERA
(Green block switch on the right) The colour bar lights up.
34 PRESS THE CAMERA BUTTON
The video level will be automatically controlled.
You can adjust the colour, but not the video level.
VIDEO RECORDER CHECKS TO BE ADDED
INSTRUCTIONS FOR SETTING UP THE VIDEO
Use a Sony DA Pro-4 head. This will be on top of the General Surgical television, or on the top of the Gynae Television.
Place it on the top of the General Surgical Television with the control panel facing forwards.
Find the video lead which should be on the video itself.
Plug the video lead into the back of the video. The socket is called Euro-AV and has a red diamond.
Plug the other end of the video lead into the back of the television in the AV socket; labelled DO NOT TOUCH!.
Check the power supply is plugged into the back, labelled AC IN.
Plug the power supply into the extension lead from the wall plug.
Check the standby light is on at red, meaning that the power is available. Press the ON STANDBY button which will show then a green light.
Check you have VHS tape with an adequate amount of free tape. The unused tape is on the left spool when you are looking at the top of the tape cassette. My tape will be in the bottom drawer of the General Surgery laparoscopic Unit.
Push the cassette through the cassette flap on the front of the video which is labelled DA PRO-4 HEAD. It will go right in and the flap will drop down again.
Next, turn to the video control handset. Lift the front lid of the handset, Press Input Select on the handset to get line 1 showing on the control display on the video front.
Hold the handset at the same height as the video machine to get a proper response here. It should show as L1 and not just 1.
Next, still holding the handset high, press the two record buttons on the handset. The red light shows on the display on the front of the video, saying record. Look for the rotating spools showing on the display and the timer will be running.
To stop the video, press either the STOP button on the front of the video or on the handset.
To fast forward, reverse, play and stop after the recording is made you press the PLAY and STOP buttons on the circular control switch, rotate the control switch as needed to reverse or forward.
For high speed rewinding, press the HIGH SPEED REWINDING BUTTON. You can also use the PAUSE button to stop.
To EJECT, press the EJECT button on the left side of the front of the video.
To insert the Timer, press the Timer on screen in the centre of the handset. To remove the Timer, press the CLEAR button, just to the right of the Timer On Screen button
35 CHECK THE LEVER IS ON DAYLIGHT 5600 K.
TV MONITORS CHECKS TO BE ADDED
36 LIGHT SOURCE CHECKS
37 PLUG IN AT WALL SOCKET
38 PLUG IN AT MULTISOCKET BOARD
39 PLUG POWER LEAD INTO THE BACK OF THE LIGHT
SOURCE
40 SWITCH ON AT WALL
41 SWITCH ON LIGHT SOURCE AT CONTROL PANEL
42 SWITCH HIGH POWER LIGHT SWITCH TO 1
This is the switch with the 6 ray sign.
43 CHECK THE START LIGHT LIGHTS UP
(= The organge start button)
44 FIRE UP THE BULB
Press the Orange start button once.
Check light comes out of the outflow.
45 SWITCH VIDEO BRIGHTNESS CONTROL TO AUTOMATIC
Manual control is possible here, with the level switch moved towards the word MANUAL.
46 ADJUST THE BRIGHTNESS
Turn the knob to the left of the level switch.
47 ADJUST THE COLOUR
(On the monitor control panel)
Adjust the picture for redness and blueness with the levers on the camera control board.
48 ?
49 INSUFFLATOR CHECKS Top
50 PLUG IN AT WALL
51 PLUG IN AT MULTISOCKET BOARD
52 PLUG POWER LEAD INTO BACK OF INSUFFLATOR
53 CHECK CO2 VALVE ON THE CO2 BOTTLE IS OPEN
54 CHECK CO2 RESERVE
The needle should be in the green quadrant on the pressure dial.
If the needle points to a lower pressure, replace the gas cylinder with a full one.
55 SWITCH ON AT WALL
56 PRESS INTERNAL TANK BUTTON
Press until the CO2 volume dial is at ZERO.
ZERO means the internal tank is full
57 PRESELECT THE CO2 PRESSURE TO 12mm MERCURY
Press the positive and negative Preselector buttons to light up the bar on the dial to 12.
58 PRESS "INSUFFLATION" ON THE FLOW BUTTON
Start it 1 litre per minute.
Check the kicking of the ball in the flow tube.
59 CHECK THE INTRA ABDOMINAL PRESSURE MEASURER
Block the CO2 outflow with your finger tip, so that the ball drops to the bottom of the tube.
Check the pressure on the display equals the pressure on the pressure Preselector.
60 SMOKE EVACUATOR CHECKS
The smoke evacuator is on the left of the Insufflator.
61 FIT THE UNSTERILE SMOKE FILTER
Place the white unsterile filter into the blue stopper in the top of the glass collecting bottle.
Check there is a tight fit.
62 FIT THE CONNECTING TUBE
Push the metal end of the connecting tube onto the unsterile filter box.
Push the other end of the connecting tube into the Pump Outlet.
The Pump Outlet is marked with "Vacuum" and an arrow pointing downwards.
63 FIT THE STERILE FILTER
Push the sterile filter onto the Out Suction.
The Out Suction has an upward pointing arrow pressure mark.
64 FIT THE RIGHT ANGLE EXTENSION TUBING
Fit the right angle extension into the insufflator Outlet Port just below the glass flow chamber.
65 FIT THE LONG CONNECTING TUBE
Fit the plastic end of the long connecting tube onto the Blue cap on the collection bottle (plastic to plastic).
Fit the metal end of the long connecting tube onto the outlet tube from the patient.
The tubing is now ready to be connected with the sterile tubing from the patient.
66 DIATHERMY CHECKS Top
67 FOR ESCHMANN DSO 402-S DIATHERMY MACHINE
68 PLUG IN AT THE WALL SOCKET
69 SWITCH ON AT THE WALL SOCKET
70 CHECK THE LEAD OF THE BLUE COAGULATION FOOT PEDAL IS PLUGGED INTO THE BACK
OF THE MACHINE
(LABELLED COAGULATION PEDAL LEAD)
71 CHECK THE LEAD OF THE YELLOW CUTTING FOOT PEDAL IS PLUGGED INTO THE BACK
OF THE MACHINE
(LABELLED CUTTING PEDAL LEAD)
72 CHECK THERE IS A DIATHERMY PAD ON THE PATIENT
Check the pad has not peeled off the patient's skin.
73 CLIP THE PAD LEAD ONTO THE DIATHERMY PAD
Check the lever or button on the lead clip faces the non-sticky side of the pad.
74 PLUG THE PATIENT PAD LEAD INTO THE SOCKET
TO THE LEFT OF THE MAN SIGN ON THE FRONT OF THE MACHINE
(Labelled patient pad lead)
75 CHECK THERE IS A BLUE PLUG IN THE DIATHERMY
LEAD SOCKET TO THE RIGHT OF THE MAN SIGN
(Labelled diathermy lead socket)
76 CHECK THE BLUE PLUG IS PUSHED FULLY HOME
77 UNSCREW FULLY THE KNOB ON THE BLUE PLUG
Unscrew the knob until the unthreaded part of the shaft is seen.
78 HOOK THE DIATHERMY HOOK ONTO THE SHAFT OF
THE BLUE PLUG
79 TIGHTEN UP THE KNOB ON THE BLUE PLUG UNTIL THE HOOK STARTS TO REVOLVE
80 PRESS THE Z SWITCH DOWN FROM 0 TO 1
81 PRESS THE NEXT SWITCH ON THE LEFT DOWN FROM 0 TO 1
82 PRESS THE 0 SIGN FOR AIR COAGULATION
83 TURN THE KNOB ON THE BLUE DIATHERMY DIAL TO 4
84 PRESS THE PAD SIGN ON THE LEFT TO GET MONOPOLAR CURRENT
A light will come on in the pad sign.
85 TURN THE KNOB ON THE YELLOW DIATHERMY DIAL
TO 4
86 PLACE THE DIATHERMY PEDALS
Place the pedals to the right of the surgeon's feet.
Place the yellow cutting pedal to the right of the blue coagulation pedal.
87 TIDY AWAY DIATHERMY LEADS FROM THE SURGEON'S
FEET
88 IF THE DIATHERMY ALARM SOUNDS
Check diathermy hook is tightly fastened
Check the diathermy lead plugs are fully pushed in
Check the slip on the diathermy pad is fastened properly
Check the pedal lead plugs are fully pushed in step number 66
CALL AN ODA
89 IF THE DIATHERMY FAILS TO BUZZ AND COAGULATE/CUT
Check the wall switch is switched on
Check the wall switch is fully pressed in
Check the monopolar pad sign is pressed
Check the pedal lead sockets are pressed home
Replace the pedal leads
Call an ODA
90 PATIENT CHECKS Top
91 CHECK YOU HAVE THE CORRECT PATIENT
92 CHECK THE DIAGNOSIS
93 CHECK THERE IS CONSENT FOR AN OPEN OPERATION IF NEEDED
94 CHECK THE PATIENT HAS EMPTIED THE BLADDER WITHIN THE HOUR
95 CHECK THERE IS A RADIO-LUCENT OPERATING TABLE FOR POSSIBLE CHOLANGIOGRAPHY
96 CHECK THERE IS A DIATHERMY PAD
97 CHECK THERE IS A NASOGASTRIC TUBE AVAILABLE
98 CHECK THE PATIENT HAS HAD 1.5G CEFUROXIME
99 ANAESTHESIA General anaesthesia Top
100 POSITION
Place the patient supine.
Wrap the arms up on the chest.
Get access from above nipples to mid-thigh and from one posterior axillary fold to the other.
Lie the patient horizontal.
101 STANCE
Stand on the patient's left side.
Place your 2nd assistant opposite.
Place your 1st assistant (cameraman) on your left.
Place the scrub nurse opposite the cameraman.
102 OFF-PATIENT EQUIPMENT POSITIONING
Place near the patient's right shoulder, the main video stand the monitor the video controller the light source
Place near the patient's left shoulder, the diathermy/sucker machine
Place near the patient's left side of face, the irrigation system
Place near the patient's right foot, the instrument table the spare equipment table Place opposite the patient's left hip the CO2 insufflator
103 SKIN PREPARATION
Clean the skin from the nipples to the pubis, and from the posterior axillary fold on one side to the posterior axillary fold on the other.
Use two swabs on sticks with 0.5% chlorhexidene in 70% propanol, followed by one to dry off.
104 TOWELLING UP
105 PLACE A PAPER TOWEL UP TO THE PUBIS
106 PLACE A LARGE LOWER TOWEL UP TO THE PUBIS
107 PLACE A LARGE TOWEL DOWN TO THE XIPHISTERNUM
108 PLACE A LEFT DRESSING TOWEL TO THE LEFT ANTERIOR AXILLARY FOLD
109 PLACE A RIGHT DRESSING TOWEL TO BEHIND THE RIGHT MID AXILLARY LINE
110 FIX THE TOWELS TO THE SKIN WITH 4 TOWEL CLIPS
111 ON-PATIENT EQUIPMENT PREPARATION
112 FIT THE EQUIPMENT TO THE RIGHT OF THE SURGEON
ie 4 LINES (2 diathermy leads + 2 plastic tubes)
113 FASTEN THE DIATHERMY HOLDER TO THE TOWELS
Place the holder on the towels over the liver so that it hangs down on the patient's right hand side.
Fasten the holder to the towels with a towel clip.
114 PLACE THE SUCKER TUBING
Place the tubing on the upper towel.
Unwind the coils thoroughly.
Pass the end to be fitted to the suction machine.
115 PLACE THE IRRIGATION TUBING
Place the tubing on the upper towel.
Unwind the coils thoroughly.
Pass the end to be fitted to the irrigation system.
116 RUN THE IRRIGATION TO REMOVE BUBBLES FROM
THE TUBING
Catch the saline in a receiver.
117 PLACE 1 DIATHERMY LEAD
Check this is the lead which will fit the hook dissector.
Place the lead on the upper towel.
Pass the end to fit on the diathermy machine.
118 PLACE THE SECOND DIATHERMY LEAD
Check this will fit the dissecting forceps.
Place the lead on the upper towel.
Pass the distal end to dangle below the towels ready for attachment to the diathermy machine if needed.
119 FASTEN SUCKER, IRRIGATION, AND THE 2 DIATHERMY
LEADS TO UPPER TOWEL
Use a towel clip
120 FIT THE IRRIGATING TUBING INTO THE SUCTION/IRRIGATION
PROBE
121 FIT THE SUCTION TUBING INTO THE SUCTION/IRRIGATION
PROBE
122 CHECK THE SUCTION PUMP IS WORKING
Adjust the suction to 0.2.
123 CHECK THE SUCTION AND IRRIGATION VALVES
WORK FREELY
124 CHECK THE SUCTION AND IRRIGATION WORK
125 PLACE THE SUCTION/IRRIGATION PROBE IN THE
DIATHERMY HOLDER
126 CHECK THE DIATHERMY PEDAL IS AT YOUR RIGHT
FOOT
127 FIT THE DIATHERMY LEAD INTO THE HOOK
ELECTRODE
128 PLACE THE HOOK ELECTRODE IN THE DIATHERMY
HOLDER
129 FIT THE EQUIPMENT TO THE LEFT HAND
OF THE SURGEON
ie 3 Lines (1 Insufflator tubing, 1 light cable, 1 camera lead)
130 PLACE THE INSUFFLATOR TUBING
Run the tubing round the right side of the drapes.
Have the insufflator end fitted into the insufflator.
131 PLACE THE LIGHT CABLE
Run the light cable round the right side of the drapes.
Have the light source end fitted into the light source.
132 HOLD OUT THE CAMERA LEAD SHEATH TO THE ODA
Have the ODA hold and keep the distal end of the sheath.
133 HAVE THE CAMERA AND CAMERA LEAD DROPPED
INTO THE SHEATH
Have the ODA hold the sheath vertically so the camera slides with its lead to within 5cm of the patient's end of the sheath.
Pinch the bottom of the sheath to prevent the camera dropping onto the sterile towels.
134 PLACE THE CAMERA LEAD AND SHEATH
Run the lead and sheath round the right side of the drapes.
135 GET THE 10MM. TELESCOPE
136 CONNECT THE CAMERA TO THE TELESCOPE
Keep the ends covered with the plastic sheath to maintain sterility.
Fit the telescope end into the camera socket by squeezing together the 2 spokes on the camera through the sheath.
Unscrew the fixed spoke to allow the camera eyepiece to rotate in the fitting.
Tighten up the fixed spoke if you wish to prevent this happening.
137 SEAL THE SHEATH AROUND THE TELESCOPE
Use the sterile adhesive strip.
Fasten the sheath tightly around the neck of the telescope.
138 FASTEN CAMERA LEAD, INSUFFLATOR, AND LIGHT
CABLE TO THE TOWELS
Use a towel clip.
Check there will be sufficient slackness in the lines to allow free movement of the camera.
139 CHECK THE CAMERA IS WORKING
140 CHECK THE LIGHT SOURCE IS SWITCHED ON
Check the light does not burn a hole in the towels or harm the patient's skin.
141 CHECK THE MONITOR PICTURE IS CLEAR
If not:
Rub the lens with a cotton wool bud moistened with saline.
Apply a drop of saline from a 2ml. syringe.
Apply a drop of liquid lens cleaner. (Ultrastop)
Shake the end of the camera to remove surplus liquid.
142 CHECK THE FOCUS
Turn the focussing collar round the neck of the telescope.
143 CHECK THE CAMERA ROTATION
Keep the 12 o'clock position on the camera at the 12 o'clock position on the monitor.
Do this by keeping the raised "Wolf" logo on the camera shaft uppermost at all times.
Make sure the cameraman understands this.
Avoid rotation of the camera under the weight of the lead.
Avoid rotation of the port which can cause kinking or detachment of the insufflation tubing.
144 CHECK THE BRIGHTNESS
Turn the Brightness control on the Camera Unit.
145 CHECK THE CONTRAST
Turn the Contrast control on the Camera Unit.
146 CHECK THE RED/ BLUE MIX
On the Camera unit.
On the Monitor controls to the left of the monitor screen.
147 CHECK THE CAMERAMAN
The cameraman controls the success of the operation.
Hold the camera with the right hand.
Steady the port with the left hand to prevent the sleeve slipping out, or causing gas leaks.
Keep the operating field in the centre of the screen.
Zoom in and out as needed.
In particular, zoom out to show the inner ends of the ports when instruments are being passed through the ports.
Avoid large and sudden movements of the camera.
Avoid accidental rotation of the camera.
Keep the camera lead slack to prevent sharp angulation damaging the lead fibres.
Have the brightness adjusted by the knob on the control panel to correct darkness or whiteouts.
148 SWITCH ON THE DIATHERMY
If the alarm sounds:
Check the diathermy lead hook is tightly fastened.
Check the diathermy plugs are fully pushed in.
Check the clip on the diathermy pad is fastened properly.
Check the pedal lead plugs are fully pushed in.
Replace the diathermy lead. Call an ODA.
149 CHECK THE DIATHERMY BUZZES ON PRESSING THE
DIATHERMY PEDAL
If not:
Check the wall switch is switched on.
Check the wall switch is fully pressed in.
Check the monopolar pad sign is pressed.
Check the pedal lead sockets are pressed home.
Replace the pedal leads.
Call an ODA.
150 CHECK DIATHERMY STRENGTH
Coagulation 4.
Use only the Coagulation current for cutting as well as coagulation.
Do not use the Cutting current.
151 PNEUMOPERITONEUM CREATION
152 CONNECT THE VERESS NEEDLE TO THE INSUFFLATOR
TUBING
Use a non-disposable Veress needle.
153 SWITCH ON CO2 FLOW AT 1 LITRE PER MINUTE
154 OPEN GAS FLOW TAP ON THE VERESS NEEDLE TO
CONFIRM A FLOW
This will show as: 0 to 2mm in the pressure register,
The ball rises in the flow column
The insufflator clicks.
A block in the needle or tubing shows up as:
12-15mm in the pressure register,
Ball does not rise in the flow column,
The insufflator does not click,
The insufflator alarm sounds.
155 SWITCH OFF THE INSUFFLATOR 1 LITRE FLOW
156 CLOSE THE GAS FLOW TAP ON THE VERESS NEEDLE Top
NB. An Autosuture disposable Veress needle has a gas flow tap which is OFF when the tap is IN LINE with the tube, unlike any other tap
157 CHOOSE A SITE FOR THE VERESS NEEDLE
Normally this is in the inferior crease of the umbilicus.
For previous surgery in the lower abdomen, use the epigastric site 2cm below and 2cm lateral to the xiphisternum.
For previous surgery in the upper abdomen, use a lateral site 2cm above the anterior superior iliac spine in the mid-axillary line.
For suspected more serious adhesions, make an opening under direct vision for the insertion of the camera port in the umbilical site.
158 UMBILICAL VERESS NEEDLE PUNCTURE
159 INCISE THE SUPRA-UMBILICAL SKIN
Use a number 15 Swann-Morton scalpel.
Make a 15mm curved incision (through the skin only) in the lower surface of the umbilicus.
160 GRASP THE SUBUMBILICAL FAT
Use your left hand to elevate and pull caudally a generous handful of abdominal wall.
If your hand is not strong enough, use 2 towel clips to elevate the periumbilical fat.
161 PUSH IN THE VERESS NEEDLE
Use your right hand.
Push the needle through the skin incision.
Aim in the midline towards the coccyx.
Rotate the needle as you pass the needle more deeply.
Feel the needle pop through the linea alba and then the peritoneum as 2 separate events.
It will feel very deep in a fat patient.
162 OPEN THE CO2 GAS TAP
163 SWITCH ON THE CO2 FLOW AT 1 LITRE/MIN
164 MAINTAIN YOUR GRASP ON THE LOWER ABDOMEN Top
Maintain the grasp until the abdomen is visibly distended with gas.
165 USE ONLY THE FOLLOWING SEQUENCE FOR THE
CO2 FLOW
1 Litre per minute
Then 4 litres per minute fixed
Then 4 litres per minute automatic
Only insufflate at the 4 litres per minute rate when you have direct vision into the peritoneal cavity.
This will minimise dangers of insufflating the abdominal wall, the falciform ligament, or vessels.
You will not be able to switch directly from the 1 litre rate to the 4 litres automatic.
166 CHECK THE CO2 DELIVERY PRESSURE FALLS TO
7-8mm MERCURY
167 CHECK CO2 IS FLOWING INTO THE PATIENT
The flow ball will rise.
The flow recorder will tick.
The abdomen will begin to distend uniformly, and will become resonant.
168 IF UNSATISFACTORY FLOW
Check the lower abdomen is properly held up.
Check the tubing is not kinked.
Move the angle of the Veress needle to clear any minor obstruction at the tip.
Check the CO2 reservoir is filled.
Check the CO2 cylinder is full.
*Check the needle is pushed in far enough.
If still unsatisfactory, remove the needle and reinsert
If unsatisfactory at a second passage, make an umbilical opening for the port under direct vision. You will need a
2/0 Vicryl (Ethicon 9125) purse string round the port to prevent a gas leak.
If you meet adhesions, consider another site.
Consider the Boring technique using a 5mm. telescope passed down a 5mm. port. If you see muscle, bore on.
If you see white, this means adhesions, so bore the telescope to a blue part with blood vessels.
Puncture only through bluish tissue.
169 IF BLOOD FLOWS UP THE VERESS NEEDLE
Resite the needle and continue with insertion of the camera to assess the cause.
If there is an expanding swelling, make an emergency laparotomy.
170 IF THERE IS A SUDDEN COLLAPSE OF THE PATIENT
This usually means a major vessel injury if the cause is intra abdominal
Non-Intra abdominal causes include:Myocardial infarct
Cardiac rhythm changes
Airway and ventilator problems
Drug reaction
Gas embolism
Tension pneumothoraxStop insufflating
Examine the peritoneal cavity
For a bleeding or expanding haematoma:Make an emergency laparotomy
Control bleeding
Restore blood volume
Repair the cause of bleeding
171 REMOVE THE VERESS NEEDLE
When there is a suitable pneumoperitoneum. ie When there is about 4 litres of CO2 in the peritoneum.
When the abdomen is obviously distended.
When the recorded pressure is 12mm
When the flow stops, showing up with a fall of the ball, and a slowing of the clicks.
172 UMBILICAL PORT INSERTION Top
173 INSERT THE UMBILICAL TROCAR AND SLEEVE
Check you have a Wolf non-disposable 10mm. trocar and port.
Check the point is sharp.
Check the valve moves freely.
Push the Trocar and port steadily through the umbilical wound, through the linea alba, and through the peritoneum.
Push towards the coccyx.
*For a disposable 10mm autosuture trocar and port (Surgiport): Check the gas stopcock is turned off (in line with the tubing).
Place the handle of the Surgiport in the palm of your hand with the writing uppermost.
Squeeze the cross piece of the Surgiport with your fingers to show up the sign "Safety Shield On".
Push the Surgiport steadily through the umbilical wound, through the linea alba, and through the peritoneum.
Push towards the coccyx.
* For insertions in the presence of adhesions or past sepsis, consider using a 5mm Port with a 5mm telescope initially, in a safe site.
Once you have confirmed the satisfactory placing of the 5mm port, replace it as needed with the standard 10mm port to revert to a normal procedure.
174 PULL OUT THE TROCAR
175 TEST THE PORT IS IN THE PERITONEUM
Squeeze momentarily on the valve to release a hiss of CO2.
* On a Surgiport, flip momentarily the tap on the top of the Surgiport to get the hiss.
If there is no hiss, replace the trocar and push the port further in.
If there is still no hiss, insert the telescope for a direct examination.
Consider an open dissection of the port opening.
176 FIT THE INSUFFLATOR TUBING TO THE PORT
177 OPEN THE PORT GAS TAP
178 SWITCH THE CO2 FLOW TO 1 LITRE FIXED
179 SWITCH THE CO2 FLOW TO 4 LITRES FIXED
180 SWITCH THE CO2 FLOW TO 4 LITRES AUTOMATIC
181 IF THERE IS A LOSS OF PNEUMOPERITONEUM:
Check for a fall in CO2 Supply: i.e. Low flow.
Check the reserve tank is not empty.
Check the CO2 bottle is not empty.
Check the insufflator tubing is not kinked.
Check a gas tap has not been closed by mistake.
Check for an excess loss of C02 ie high flow.
Check the port has not slipped out of the peritoneum. Push the port back into the peritoneal cavity, and hold it there by hand.
If there is any difficulty in pushing the port back in, replace it formally using the trocar.
For a loose port which is leaking, slipping in or out, insert a disposable bung.
Check insufflator tubing has not fallen of the port.
Check excess use of suction.
Check loose converter.
Check loss of converter rubber seal.
182 UMBILICAL CAMERA INSERTION Top
183 INSERT THE CAMERA DOWN THE UMBILICAL PORT
Open the valve before the camera hits it to prevent blood staining the lens.
184 CAMERA HANDLING
185 TOUCH THE PERITONEUM WITH THE CAMERA
This will warm the lens and prevent misting.
186 CHECK THE PICTURE
If there is no picture, clean the lens.
If there is still no picture, suspect an omental flap.
Remove the telescope.
Put the telescope back in the port.
If the picture is still not clear, remove the telescope and port.
Consider another site for the camera port.
187 IF THERE IS A HAZY PICTURE:
Clean the lens again.
Clean the top of the port.
Check the focus.
Check the camera and laparoscope ends are dry.
Check the colour/brightness.
Check the signal output is adjusted.
188 IF THERE IS A GOOD PICTURE
CONTINUE
189 CHECK FOR DAMAGE BY NEEDLE OR TROCAR Top
Minor bruises and scratches on the viscera -ignore.
Moderate bleeding
- use diathermy.
Major bleeding
- use Ligaclips or ligatures
Simple perforation of bowel
- treat expectantly.
Tears or complete tranfixion of bowel by the trocar and port
- open laparotomy and repair/ resection.
Bladder perforation
- Foley catheter for 7 days.
A bleeding or expanding haematoma
- open laparotomy and control the bleeding.
Insufflation of preperitoneal, retroperitoneal, omental, mesenteric or falciform ligament tissues
- Ignore
Choose another site for insertion of the port if necessary, and wait for the CO2 to absorb.
190 EXAMINE THE LOWER ABDOMEN AND PELVIS FOR
OTHER PATHOLOGY
191 EXAMINE THE UPPER ABDOMEN
Check that the epigastric port site is free from adhesions.
If there are adhesions, choose a lateral site. (Use the 5mm trocar and telescope if available.)
192 EPIGASTRIC OPERATING PORT INSERTION Top
193 CHOOSE AN EPIGASTRIC PORT SITE
This will be through the peritoneum 2cm to the right of the falciform ligament, 2cm Below the xiphisternum.
194 SURFACE MARK THE EPIGASTRIC PORT SITE
Tap on the skin to show the correct underlying peritoneum moving.
Transilluminate the abdominal wall with the camera end to show up any blood vessels in the wall.
195 INCISE THE SKIN
Use a no 15 Swann Morton blade.
Make a 15mm transverse incision through the skin only.
Avoid incising where there are underlying blood vessels.
196 CHECK THE 10mm TROCAR AND PORT
Check the port valve piston moves smoothly.
Check the stopcock is turned off.
197 INSERT THE EPIGASTRIC TROCAR AND PORT
Use a non-disposable trocar and sleeve.
Press through the fat, rectus sheath and peritoneum.
Check the point of the trocar comes through the peritoneum to the right of the falciform ligament.
If the point catches in the falciform ligament, or is to the left of it, remove the trocar and reinsert in the correct place.
Push the trocar towards the gallbladder to avoid damage to other tissues.
198 REMOVE THE EPIGASTRIC TROCAR
199 IF THERE IS BLEEDING/ HAEMATOMA FROM THE
EPIGASTRIC VESSELS
eg Blood dripping down the outside of the port into the peritoneum.
Do not remove the trocar and port.
For a haematoma only, insert deep sutures through the abdominal wall cranially and caudally.
Use a suture introducer.
If moderate bleeding, coagulate the peritoneum cranial and caudal to the port to control the epigastric vessels.
If severe bleeding, incise the anterior abdominal wall to clamp and suture the ends of the bleeding vessels.
* Check bleeding has stopped.
200 INSERT A 5MM. REDUCING SLEEVE
Use a non-disposable sleeve.
Push the reducing sleeve 2cm into the 10mm port
Press in the piston on the 10mm port
Push the reducing sleeve right into the 10mm port
201 INSERT THE HOOK ELECTRODE
202 EXAMINE THE UPPER ABDOMEN
Use the hook as a probe.
203 CHECK FOR DAMAGE BY THE TROCARS AND VERESS NEEDLE
204 ADHESION DIVISION Top
Use hook electrode.
IMPORTANT: the electrode remains dangerously hot for 30 seconds or more after coagulation. Make sure you do not let the hot electrode touch the viscera during this time. This may happen when the hook is out of the operating field or field of view.
Dissect the right side of the peritoneum.
The dissection will free the peritoneum for insertion of the 2 lateral ports.
Only free as much tissue as is needed for a clear view of the port sites.
Cut the tissue at its junction with the peritoneum.
Avoid cutting the omental fat which will bleed.
205 MIDCLAVICULAR RETRACTING PORT INSERTION
206 CHOOSE A MIDCLAVICULAR PORT SITE
2cm Below the costal margin in the mid clavicular line.
Tap the skin to check the underlying peritoneum is clear of adhesions.
Transilluminate the abdominal wall to avoid vessels.
207 INCISE THE SKIN
Use a no 15 Swann - Morton scalpel.
Make a 7mm Transverse incision through the skin only to avoid bleeding, and to make a gas tight fit with the sleeve.
208 INSERT THE 5MM TROCAR AND PORT
Use a non-disposable 5mm trocar and port.
Push steadily through the fat.
See the point of the trocar pushing through cleared peritoneum.
Push until the port projects 3cm into the peritoneal cavity.
209 MID-AXILLARY RETRACTING PORT INSERTION
210 CHOOSE THE MID-AXILLARY PORT SITE
5cm Above the anterior superior iliac spine in the mid axillary line.
This should be in line with the mid- clavicular and the epigastric ports.
Tap the skin to check the underlying peritoneum is clear of adhesions.
Transilluminate the abdominal wall to avoid vessels.
211 INCISE THE SKIN
Use a no 15 Swann-Morton scalpel.
Make a 7mm Transverse incision through the skin only to avoid bleeding, and to make a gas tight fit with the port.
212 INSERT A 5MM TROCAR AND SLEEVE
Use a non-disposable 5mm trocar and sleeve.
Push steadily through the fat and abdominal wall.
See the point of the trocar pushing through cleared peritoneum.
Push until the sleeve projects 3cm into the peritoneal cavity.
213 INSPECT THE ABDOMINAL CONTENTS Top
Empty the stomach with a naso-gastric tube if it is getting
in the operating field.
Tilt the operating table to the left and foot down as needed to get the clearest
view.
Push omentum and colon out of the field of view with the hook electrode.
214 CHECK FOR INSTRUMENTAL DAMAGE
215 CHECK FOR OTHER PATHOLOGY
216 GALLBLADDER FUNDUS RETRACTION
217 PASS THE GRASPING FORCEPS THROUGH THE MID-AXILLA
PORT
Use the alligator grasping forceps (-13).
218 GRASP THE FUNDUS OF THE GALLBLADDER
Slide the open forceps down the gallbladder from its apex to the fundus to get a satisfactory grip.
Free any adhesion from the fundus using the hook to let the forceps grasp the fundus.
If the gallbladder is too distended for easy grasping, puncture it with the 5mm trocar through the mid-clavicular port at a site on the fundus suitable for grasping by the mid-axilla forceps.
Suck out liquid contents with the sucker.
Clip the puncture site with the grasping forceps through the mid-clavicular
Close any unsuitable puncture site or accidental opening with an Endoloop.
If the fundus is still too thickened for grasping, wait for the gallbladder to be freed by later dissection before grasping the fundus.
Elevate the gallbladder for access using a closed forceps as a simple elevator.
If the gallbladder is fibrosed and shrunken: Consider a trial dissection.
Stop if the cystic duct is very thick (more than 15mm).
Stop if the anatomy is not clear. ie Calot's triangle is not visible.
(Cystic duct runs west, the common bile duct runs north).
Consider an open cholecystectomy.
219 HOLD THE FUNDUS OF THE GALLBLADDER UP TOWARDS
THE DIAPHRAGM
Use the alligator grasping forceps (-13).
Get the 2nd assistant to maintain a firm upward traction on the fundus to assist further dissection.
220 HARTMANN'S POUCH RETRACTION
Use the racquet grasping forceps (-141).
If there are adhesions, clear them with the hook electrode.
Aim to clear the whole of the gallbladder, gallbladder neck, and the peritoneum over the cystic duct.
Take your time.
It may take up to an hour.
Concentrate on the junction between the gallbladder and the adhesions.
Pull the hooked tissue towards the camera as you coagulate, to prevent coagulation damage to the bowel wall and liver.
Maintain a firm traction on the fundus and the neck of the gallbladder.
This will aid the dissection of the adhesions.
Dissect from the gallbladder down towards the cystic duct to clarify the anatomy.
For a stone impacted in Hartmann's Pouch: Try pushing the stone and Hartmann's pouch laterally with half open racquet forceps to display the cystic duct.
Consider cutting down onto the stone with scissors and removing it.
221 CYSTIC ARTERY AND DUCT DISSECTION
222 IF YOU HAVE A POOR VIEW OF THE CYSTIC DUCT/ARTERY
AREA:
223 CHECK THE TENSION ON THE FUNDUS AND THE
NECK
Keep the fundus held firmly up towards the diaphragm.
Adjust the grip on Hartmann's pouch.
Let omentum fall away on its own.
Rolling the table to the left may help clear the omentum away.
Pull on the peritoneum and adventitia around the cystic artery and duct so that they form strands for easier dissection.
Slide the camera under an enlarged right lobe of liver to act as a retractor.
Use the alligator forcep to retract a deformed chest as well as the fundus of the gallbladder.
224 IDENTIFY THE ANATOMY Top
Remind yourself of:
Hartmann's pouch.
The neck of the gallbladder.
The duodenum.Look for the possible positions of:
Cystic duct.
Cystic artery (Beware of anterior and posterior branches).
Right and left hepatic artery.
Common bile duct.You may not be certain of the anatomy at this point.
Expect the anatomy to emerge as you dissect.
Common variants include:
Tented common bile duct.
Distended cystic duct resembling the common bile duct.
Neck of the gallbladder resembling a distended cystic duct.
Long cystic duct running down alongside the common bile duct.
Very short (or zero) cystic duct.
Right hepatic artery looping laterally into the operating field.
Aberrant cystic artery running across the cystic duct from the gastro-duodenal artery.
More than 1 cystic artery.
Branching cystic artery.
Absent cystic artery.Consider an elective conversion for:
Calot's triangle obscure.
Hartmann's pouch adherent to the common bile duct.
Absent cystic duct (Mirrizzi's syndrome).
Excessive fibrosis and scarring.
225 CONTINUE DISSECTING THE CYSTIC DUCT AND ARTERY Top
This dissection will be more difficult than division of adhesions.
Take your time.
It may take up to an hour.
Aim to skeletalise the duct and artery.
The cystic duct will probably appear before the cystic artery.
Concentrate on dividing strands of peritoneum, adventitia, nerve fibres, and very small blood vessels.
Avoid bleeding.
Control minor bleeding as you go.
If you suspect a strand is a minor vessel, coagulate it in 2 places before cutting in between.
Aim to clear a 20mm length of cystic artery and a 20mm length of cystic duct.
You also need to identify the common bile duct, the hepatic duct, and non-cystic duct vessels.
Dissect the posterior aspect of the structures as much as the anterior aspect, unlike an open cholecystectomy.
Extend the dissection onto the posterior and anterior sides of the gallbladder 2mm from the liver to get better access.
Swing the neck of the gallbladder from side to side liberally to be sure about the anatomy.
Divide the strands behind the cystic duct and artery to make sure there is enough space for the clip applicator jaws.
Run the hook electrode up and down behind the cystic artery and duct to make sure that they are completely free.
226 DEALING WITH BLEEDING
Don't panic.
The camera magnifies the bleeding alarmingly.
Try local pressure with the hook electrode.
Connect the diathermy forceps to the diathermy machine.
Put the suction/irrigator in the mid- clavicular port.
Put the diathermy forceps in the epigastric port.
Grasp a 1-2mm vessel precisely with forceps and coagulate it.
Grasp a larger vessel with forceps and wait for 3 minutes to allow spontaneous coagulation.
Dissect out a vessel held in forceps to allow clipping.
Wait 10 minutes before deciding on an open operation.
For uncontrollable bleeding, do a laparotomy.
If you have not found the cystic artery, check you have interpreted the anatomy correctly.
You may have mistaken the common bile duct for the cystic duct.
If there is definitely no cystic artery visible now, be prepared to find the artery or branches when dissecting the gallbladder.
GO TO STEP 245 (CLIPPING THE CYSTIC DUCT).
228 CHECK THE CYSTIC ARTERY DIAMETER
If the artery is 4mm or less (90% of cases), use 300 Ligaclips.
If the artery is more than 4mm, check it really is the cystic artery.
For a cystic artery more than 4mm, use an extra large 400 Ligaclips or an Endoloop.
229 TAKE OUT THE HOOK ELECTRODE
230 TAKE OUT THE 5MM. REDUCING SLEEVE
231 CHECK THE CLIP APPLIER
Check it is a non-disposable medium Ligaclip applier.
Check it is loaded with a 300 Ligaclip.
For a disposable clip applier:Check it is an Autosuture Endoclip ML Disposable Applier with Medium- Large Titanium clips.
Check the clips are present.
Test load 1 clip.
Test fire 1 clip.
Remove the fired clip.
Check the jaws rotate easily.
232 CHECK THE SCISSORS
Check they are the Wolf Hooked scissors with single action blade (8383-45)
Check the scissors will cut an arterial Sloop.
Check you have a spare pair of scissors.
233 INSERT THE CLIP APPLIER
234 TEST THE DISSECTION OF THE CYSTIC ARTERY
Place the jaws of the applier at the 2 planned sites for clipping, 20mm apart on the artery.
Rotate the jaws to get the neatest siting of the applier.
If you do not have a clear view of the back of the back jaw, dissect some more strands with the hook electrode.
235 PUT THE FIRST CLIP ON THE CYSTIC ARTERY
This is the first of 3 clips on the artery.
(For a disposable applier, hold the applier 5mm from the artery.
Load the applier by pressing the loading button on the applier handle.
Check a clip loads into the jaws.)
236 FIT THE JAWS ON THE CYSTIC ARTERY
Choose the most distal site from the hepatic artery.
Rotate the jaws for the best angle.
Make sure you do not rub the clip out of position in the jaws.
Check the posterior jaw is clearly visible.
237 CLIP THE ARTERY
Close the jaws smoothly and slowly by steadily squeezing the handles of the applier as hard as you can.
Avoid any jerking movement.
Release the handles gently.
Carefully withdraw the jaws from the clipping zone.
238 CHECK THE FIRST CLIP
Check it is:
At the correct site.
At exactly 90 degrees to the cystic artery.
Projecting 1mm at least beyond the artery.
Not attached to any other structure.If the clip has fallen off:
Ignore it and start the clipping afresh.
If the clip is loose: or does not extend completely across the artery:or is lying obliquely:
Start clipping afresh, distal to the unsatisfactory clip.
Do not place 1 clip on top of another.
Do not try to fit 2 clips end to end across a wide vessel.
If the applier is stiff in the port, lubricate it with saline.
Use a disposable port if a non-disposable port is causing serious sticking.
239 RELOAD THE NON-DISPOSABLE CLIP APPLIER
(For a disposable applier GO TO STEP 243 (Put the second slip on the artery))
240 WITHDRAW THE CLIP APPLIER
241 FIT A NEW CLIP ONTO THE APPLIER
Keep hold of the applier handle.
Push the jaws firmly onto the next clip in the rack guided by the scrub nurse.
Check the clip is firmly held by the jaws.
242 INSERT THE CLIP APPLIER
243 PUT THE SECOND CLIP ON THE CYSTIC ARTERY
Use the same technique as for the first clip.
Place it on the artery adjacent to the first clip on the gallbladder side.
Make sure it does not override the first clip.
Manage clipping problems as for the first clip.
244 PUT THE THIRD CLIP ON THE CYSTIC ARTERY
Use the same technique as for the first clip.
Place it on the artery 15mm distal to the second clip.
If there is not 15mm. Of artery free, dissect out the artery more fully distally.
Manage clipping problems as for the first clip.
245 CYSTIC DUCT CLIPPING Top
246 CHECK THE CYSTIC DUCT DIAMETER
If the duct is 4mm Or less (90% of cases), use 300 Ligaclip clips.
If the duct is more than 4mm In diameter, check by further dissection, that it is not, in fact, the neck of the gallbladder or the common bile duct.
For a cystic duct more than 4mm, Use an extra large 400 Ligaclip or an Endoloop.
Consider an Endo GIA 30-3.5 stapler via a 12mm Port
247 LOAD THE CLIP APPLIER
(For a disposable applier, hold the applier 5mm from the duct.
Load the applier by pressing the loading button on the applier handle.
Check a clip loads into the jaws.)
248 FIT THE JAWS ON THE CYSTIC DUCT
Choose a clear site on the gallbladder end of the cystic duct, out of any danger of the common bile duct.
Rotate the jaws for the best angle.
Make sure you do not rub the clip out of position in the jaws.
Check the posterior jaw is clearly visible.
249 CLIP THE DUCT
Close the jaws smoothly and slowly by steadily squeezing the handles of the applier as hard as you can.
Avoid any jerking movement.
Release the handles gently.
Carefully withdraw the jaws from the clipping zone.
250 CHECK THE FIRST CLIP
Check it is:
At the correct site.
At exactly 90 degrees to the cystic duct.
Projecting 1mm at least beyond the duct.
Not attached to any other structure.If the clip has fallen off:
Ignore it and start the clipping afresh.
If the clip is loose: or does not extend completely across the duct:or is lying obliquely:
Start clipping afresh, on the gallbladder side of the unsatisfactory clip.
Do not place 1 clip on top of another.
Do not try to fit 2 clips end to end across a wide vessel.
If the applier is stiff in the port, lubricate it with saline.
Use a disposable port if a non-disposable port is causing serious sticking.
251 RELOAD THE NON-DISPOSABLE CLIP APPLIER
(For a disposable applier GO TO STEP 255 (Put the second slip on the duct))
252 WITHDRAW THE CLIP APPLIER
Seal the convertor end with your left index finger to prevent CO2 loss.
253 FIT A NEW CLIP ONTO THE APPLIER
Keep hold of the applier handle.
Push the jaws firmly onto the next clip in the rack guided by the scrub nurse.
Check the clip is firmly held by the jaws.
254 INSERT THE CLIP APPLIER
255 PUT THE SECOND CLIP ON THE CYSTIC DUCT
Use the same technique as for the first clip.
Place it on the duct adjacent to the first duct clip on the gallbladder side.
Manage clipping problems as for the first clip.
256 PUT THE THIRD CLIP ON THE CYSTIC DUCT
Use the same technique as for the first clip.
Place it on the duct 15mm or more from the the second clip.
If there is not 15mm of duct free, dissect out the duct more fully.
Manage clipping problems as for the first clip.
257 CYSTIC ARTERY CUTTING Top
258 ***ALWAYS CUT THE ARTERY BEFORE CUTTING
THE DUCT
This will prevent the artery tearing.
If you have not found a cystic artery, be prepared to find one (or more) when dissecting the gallbladder later. GO TO STEP 263 (CYSTIC DUCT CUTTING)
259 TAKE OUT THE CLIP APPLIER
260 INSERT THE SCISSORS
261 POSITION THE SCISSORS
Place the scissors across the cystic artery between the single and the double clips.
Place the non-moving scissor jaw behind the artery.
Manoeuvre the jaws to lie at 90 degrees to the artery, 10mm distal to the second clip.
Check there are no intervening strands of tissue.
Check you can see the ends of the scissor jaws.
262 CUT THE CYSTIC ARTERY
Use a smooth steady cutting action.
If the scissors do not cut completely through the artery at the first attempt, repeat the cutting action once. If the scissors do not cut properly at the second attempt, change them for a spare pair.
Use a disposable pair (Endoshears), if there are any more problems.
For a bleeding from the cystic artery:Don't panic.
The camera magnifies the bleeding alarmingly.
Apply another clip if the anatomy is clear.
Do not insert clips blindly.
Connect the diathermy forceps to the diathermy machine.
Put the suction/irrigator in the mid-clavicular port.
Put the diathermy forceps in the epigastric port.
Consider inserting an extra port.
Use plenty of irrigation.
Try local pressure with the forceps.
Grasp a 1-2mm vessel precisely with forceps and coagulate it.
Grasp a larger vessel with forceps and wait for 3 minutes to allow spontaneous coagulation.
Dissect out a vessel held in forceps to allow clipping.
Wait 10 minutes before deciding on an open operation.
For uncontrollable bleeding, do a laparotomy.
Consider an emergency laparotomy.
263 CYSTIC DUCT CUTTING Top
264 POSITION THE SCISSORS
Place the scissors across the cystic duct between the single and double clips.
Place the nonmoving scissor jaw behind the duct.
Manoeuvre the jaws to lie at 90 degrees to the duct, 10mm distal to the second clip.
Check there are no intervening strands of tissue.
Check you can see the ends of the scissor jaws.
265 CUT THE CYSTIC DUCT
Use a smooth steady cutting action.
If the scissors do not cut completely through the duct at the first attempt, repeat the cutting action once.
If the scissors do not cut properly at the second attempt, change them for a spare pair.
Use a disposable pair (Endoshears), if there are any more problems.
If there is bile leakage from the proximal cystic duct, apply a further clip if the anatomy is clear.
If the clip is ineffective, try an Endoloop.
If the Endoloop is ineffective, consider an emergency laparotomy
266 CHECK THE CYSTIC DUCT AND ARTERY
Check the vessel clips are tightly fastened.
Check there is not the slightest oozing from the vessel stubs.
For suspected common bile duct damage, do a conversion.
267 GALLBLADDER DISSECTION Top
268 CHECK THE TRACTION ON THE GALLBLADDER
Adjust the traction on the gallbladder fundus in case cutting the cystic artery and duct has slackened the tissues.
269 START THE GALLBLADDER DISSECTION
Use the diathermy hook.
Aim to free the gallbladder from its bed from the neck of the gallbladder to the fundus.
Cut strands of tissue as they present themselves.
This means dissecting from side to side freely.
Maintain the tension on the gallbladder to show up the strands.
Cut the peritoneum before cutting the deeper strands.
Cut the peritoneum where it is attached to the gallbladder, 2mm from the liver.
Avoid cutting the peritoneum on the liver and the liver itself.
Avoid cutting the gallbladder.
Avoid flicking the electrode onto the liver or other viscera during this dissection.
Take your time.
Be on the alert for arteries needing clipping.
If there is bleeding from the gallbladder bed during this dissection, apply local pressure using the gallbladder as a pack.
Move to a different part of the dissection while waiting for minor bleeding to stop.
Return to the bleeding site after 2 minutes.
Remove any blood with the suction irrigator.
Coagulate any bleeding vessel with the hook STEP NUMBER 269 electrode.
Coagulation/cutting diathermy at level 2 may be better than normal Coagulation to control a bleeding liver bed.
If bleeding persists, repeat the packing/coagulation.
If packing/coagulation fails a second time, consider an open operation.
If the gallbladder leaks, aspirate the bile and biliary mud.
If stones escape from the gallbladder, retrieve accessible stones with racquet forceps.
Leave inaccessible stones behind.
270 FINISH THE GALLBLADDER DISSECTION
As the dissection continues, retract the freeing gallbladder more and more upwards over the liver edge towards the diaphragm.
This will give access to the more distal gallbladder bed.
Dissect steadily through the strands.
Do not rush.
Finish the dissection slowly.
Wash/irrigate the gallbladder bed before cutting the last strands.
If the last strands make the gallbladder difficult to control, pull the gallbladder downwards and cut the peritoneum with the hook from the superior surface.
This manoeuvre will help avoid tearing the last strand of peritoneum between the gallbladder and the liver.
271 STORE THE GALLBLADDER ABOVE THE LIVER
Keep hold of the freed gallbladder with the alligator forceps on the fundus.
272 CHECK FOR BLEEDING
Use the suction irrigator to irrigate and then aspirate blood, blood clots and any bile.
Avoid aspirating CO2, which causes very rapid loss of pneumo-peritoneum and vision.
Aspirate any blood from the right subphrenic space.
Aspirate any blood from the right subhepatic space.
Aspirate any blood from the gallbladder bed.
Manage bleeding as before.
Look out for bile leakage from the gallbladder bed.
Manage gallbladder bed bile leakage as for bleeding with coagulation.
Check the cystic duct and artery for leakage.
273 DECIDE ABOUT DRAINAGE Top
Usually no drainage is needed.
Drain if there is excessive oozing from the gallbladder bed, or a treated gallbladder bed bile leak.
Pass a Portovac drain through the mid-clavicular port perforations first.
Clamp the drain externally with an artery forceps to prevent a CO2 leak.
Position the perforated part of the drain in the gallbladder bed.
274 GALLBLADDER REMOVAL Top
275 REMOVE THE DIATHERMY HOOK
276 REMOVE THE EPIGASTRIC CONVERTOR
277 PLACE THE ROTWEILER FORCEPS IN THE EPIGASTRIC
PORT
278 SHOW THE ROTWEILER FORCEPS ON THE SCREEN
279 SWING THE ROTWEILER FORCEPS TO ABOVE THE
LIVER
280 GRASP THE GALLBLADDER
Use the Rotweiler forceps.
Grasp the neck of the gallbladder at the clip.
281 PULL THE GALLBLADDER TOWARDS THE EPIGASTRIC
PORT
282 PULL THE EPIGASTRIC PORT OUT WITH THE ROTWEILER
FORCEPS
283 PULL THE GALLBLADDER UP INTO THE EPIGASTRIC
WOUND
Rarely, the gallbladder will pull easily out through the wound at this stage. GO TO STEP 290 (Pull out the gallbladder)
Usually, the gallbladder is too distended to pass through the wound.
READ ON
284 GRASP THE GALLBLADDER NECK OUTSIDE THE WOUND
Use 2 Robert's forceps to hold the corners of the gallbladder.
Use these to prevent the gallbladder dropping back into the peritoneal cavity.
If the gallbladder drops back into the peritoneal cavity, replace the port and equipment to find the gallbladder again.
285 OPEN THE GALLBLADDER
Use 2 Robert's forceps to hold the gallbladder wall above the skin.
Open the intervening gallbladder wall with a no.15 Swann-Morton blade.
286 SWAB THE BILE
Send the specimen for culture.
287 ASPIRATE THE GALLBLADDER
Use the suction/irrigator.
Remove all bile to reduce the size of the gallbladder.
Try to avoid contaminating the epigastric wound with potentially infected bile.
288 TRY PULLING OUT THE GALLBLADDER
If the gallbladder comes out, GO TO STEP 289 (Pull out the gallbladder) If not, READ ON
289 ENLARGE THE EPIGASTRIC OPENING
Push a slightly angled grooved director into the epigastric opening to protect the gallbladder.
ie the grooves facing away from the gallbladder.
Cut the linea alba 1-2mm downwards with a no.15 Swann-Morton scalpel to relieve the tightness on the gallbladder and its contained gallstones.
290 PULL OUT THE GALLBLADDER
It is difficult to make this move look elegant.
Repeat the cutting of the linea alba as needed.
Cut the skin in the same way if the skin opening is too small.
Avoid bursting the gallbladder by trying to pull it through too small a hole.
If gallstones spill back into the peritoneal cavity, ignore them.
291 SEND THE GALLBLADDER FOR HISTOLOGY
292 REMOVE THE MID-AXILLA FORCEPS Top
293 REMOVE THE MID-AXILLA PORT
294 REMOVE THE MID-CLAVICULAR PORT
If there is a drain, make sure the port slides out over the drain.
Stitch the drain with a no.1 silk stitch (Ethicon W799) with 4 throws to the skin, wrapped round the drain 4 times, tied again with 4 throws, and the ends cut 4cm long.
295 REMOVE THE CAMERA
296 PRESS OUT EXCESS CO2
Use the umbilical port with the piston valve open.
297 REMOVE THE UMBILICAL PORT
298 SWITCH OFF THE INSUFFLATOR
This will prevent the CO2 bottle emptying.
299 SWITCH OFF THE LIGHT SOURCE BULB
Let the Light Source fan run for a further 10 minutes.
300 CHECK THE SWAB, NEEDLE, AND INSTRUMENT COUNTS
301 WOUND CLOSURE
Close an epigastric port of over 15mm. diameter with 2/0 Vicryl (Ethicon 9125).
Use Suture Strips to the skin.
302 APPLY COMPLIANT DRESSINGS
Mepore.
303 REMOVE ANY NASO-GASTRIC TUBE
304 CHECK THERE IS NO OTHER PROCEDURE TO DO
305 CONNECT UP THE SUCTION SYSTEM
CLOSURE Top
306 FINAL TOUCHES
307 FILL IN THE HISTOLOGY AND BACTERIOLOGY FORMS
308 WRITE LEGIBLE OPERATION DETAILS
309 FILL IN THE SURGICAL AUDIT FORM
310 FILL IN THE LAPAROSCOPIC CHOLECYSTECTOMY
AUDIT FORM
311 DICTATE AN OPERATION LETTER TO THE GENERAL
PRACTITIONER PLUS A COPY TO THE REFERRING PHYSICIAN
312 SWITCH OFF POWER TO VIDEO TV MONITORS LIGHT
SOURCE INSUFFLATOR DIATHERMY
Provided another laparoscopic cholecystectomy is not being done on the operating session.
313 CLOSE CO2 BOTTLE
314 END OF OPERATION
SURGEON..........M.H.EDWARDS
INDEX Top
5 99
0 Laparoscopic cholecystectomy theatre layout
1 Non-surgical equipment
2 Video system
3 Video recorder
4 Light source
5 Cables
6 Insufflation system
7 Spares
8 Standard sterile surgical instruments
(FRIARAGE HOSPITAL)
9 Standard sterile surgical instruments
(DARLINGTON MEMORIAL HOSPITAL)
10 Standard sterile surgical instruments
(ST JOHN OF GOD HOSPITAL)
11 Special sterile surgical instruments
12 Telescopes
13 Trocars and sleeves
14 Veress needle
15 Forceps, scissors and clip appliers
16 Suction/irrigation probes
17 Electrodes
18 Miscellaneous
19 Surgical disposables
20 Surgical disposable spares
21 Theatre furniture
22 Surgical materials
23 Pharmaceuticals
24 Assorted extras and items for future purchase
26 Video camera checks
34 Video recorder checks
35 TV Monitors checks
36 Light source checks
49 Insufflator checks
60 Smoke evacuator checks
66 Diathermy checks
90 Patient checks
99 Anaesthesia
100 Position
101 Stance
102 Off-patient equipment positioning
103 Skin preparation
104 Towelling up
111 On-patient equipment preparation
151 Pneumoperitoneum creation
158 Umbilical Verress needle puncture
169 If blood flows up the Veress needle
170 If there is a sudden collapse of the patient
172 Umbilical port insertion
182 Umbilical camera insertion
184 Camera handling
192 Epigastric operating port insertion
204 Adhesion division
205 Midclavicular retracting port insertion
209 Mid axillary retracting port insertion
216 gallbladder fundus retraction
220 Hartmann's pouch retraction
221 Cystic artery and duct dissection
226 Dealing with bleeding
227 Cystic artery clipping
245 Cystic duct clipping
257 Cystic artery cutting
263 Cystic duct cutting
267 gallbladder dissection
274 gallbladder removal
301 Wound closure
306 Final touches
314 End of operation