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Design a consent form specifically for laparoscopy, listing the main risks (both general and
specific) of laparoscopic surgery.
Model answer
You should consider how to express in plain English the risks listed below. When counselling
patients for surgery it is imperative that you use appropriate language and check
understanding.
venous thromboembolism
atelectasis leading to infection
MI or CVA
death
You may wish to refresh your knowledge of the GMC guidelines on consent:
In order to perform laparoscopic surgery appropriately, the level of expertise of the surgeon is
critical, as is support from other surgical disciplines. For most procedures, experienced
assistance is needed and becomes increasingly important as the complexity of surgery
increases.
Many surgical centres in Europe and increasingly in the UK have more than one advanced
laparoscopic surgeons, who will operate together for exactly this reason. Experienced
anaesthetic support is equally important in understanding the unique effects of a
pneumoperitoneum on respiratory and cardiac function as well as an appreciation of the
particular operative challenges the surgeon faces.
Finally, the theatre set-up is also vital in terms of staff and equipment. Without experienced
theatre staff that are familiar with the range of equipment and instruments required during
laparoscopy, safe surgery is impossible.
You only have to have experienced the difficulties associated with performing an emergency
laparoscopy outside normal hours with unfamiliar staff to appreciate how important this is. It
is the operating surgeon's responsibility to be familiar with all equipment or instruments that
they intend to use.
Model answer
1. Patient positioning is crucial to successful surgery and this is particularly true during
laparoscopic surgery. It is good practice for the operating surgeon to supervise positioning of
the patient prior to scrubbing. A non-slip mat is essential for all procedures
2. If the patient is too high up the table, full anteversion of the uterus will not be possible,
compromising the operative view of the pelvis. Conversely, if positioned too low, the patient is
at risk of musculoskeletal injury due to inadequate support of the lower back and sacrum
3. Ideally, specially designed lithotomy stirrups should be used to support the patient's
legs. As well as providing padded support for the legs, the position can be adjusted by the
surgeon during surgery. This is especially useful for combined hysteroscopic and laparoscopic
surgery, or for laparoscopic assisted vaginal hysterectomy
4. If conventional poles with stirrups are used, gel padding should be placed between the
leg and pole to avoid peripheral nerve injuries
5. The lower back should be well supported with the buttocks just over the end of the
table
6. The patient's arms need to be secured away from the operating field and allow
anaesthetic access to peripheral cannulae
7. Remember that the entire abdomen, from xiphisternum to pubis, constitutes the
potential operating field and needs to be available to the surgeon. Changing the position of
arms or drapes during surgery causes unnecessary delay as well as potentially contaminating
the surgical site
8. For prolonged laparoscopic procedures, warming blankets or 'bear-huggers' should be
used as well as thromboembolic deterrent stockings
9. Contrary to popular belief, routine bladder catheterisation is not required for the
majority of patients undergoing laparoscopy
This practice stems from the original practice of suprapubic placement of the Veress needle
for insufflation, which risked bladder injury. The first sensation to void is typically 200 ml and
is likely to be lower in a nervous pre-operative patient.
The bladder needs to contain in excess of 250 ml to extend above the pubic symphisis and this
can easily be excluded during the routine bimanual examination that is performed at the start
of each case. Postoperative urinary retention is associated with extensive dissection,
prolonged procedures and postoperative pain.
In view of this, indwelling catheters are recommended for patients undergoing complex
surgery.
Model answer
Your answer should include preoperative preparations standard to any obese patient.
Additional considerations include the equipment requirements, e.g. operating table limitations,
longer trocars and Veress needles, surgical and assistant expertise. Finally you should
consider the postoperative recovery time and how this patient will be managed.
Consider:
Should you encounter a complication such as bowel injury, what back up would be available
from your general surgical team? Should this operation include their input?
Case studies
Tasks
o Selection for surgery 1
o Selection for surgery 1 - model answer
o Selection for surgery 2
o Selection for surgery 3
o Selection for surgery 3 - model answer
o Selection for surgery 4
o Selection for surgery 4 - model answer
o Theatre setup 1
o Theatre setup 1 - model answer
o Theatre setup 2
o Theatre setup 2 - model answer
o Entry techniques 1
o Entry techniques 1 - model answer
o Entry techniques 2 - model answer
o Entry techniques 2
o Entry techniques 3
o Entry techniques 3 - model answer
o Secondary ports
o Secondary ports - model answer
o Monopolar and bipolar current
o Monopolar and bipolar current - model answer
Short answer question
Most surgeons employ what we will call the classic approach. An incision is made below the
umbilicus, the abdominal wall is grasped firmly and a Veress needle is passed at 45°. Once its
position is felt to be correct, 2–3 litres of gas is insufflated and the primary trocar inserted at
45°.
Most complications follow this method; hence, alternatives have been developed. The
argument, "I have always done it this way and not had problems" is untenable, as only the
statistics of low complication rates protect these surgeons, not their skills.
This is a very rapid technique that will avoid any complications related to the use of the
Veress needle. It will not, however, avoid primary trocar injury.
In Jansen's study, for instance, only five major complications from 70 607 laparoscopies were
attributed to Veress needle, as opposed to 68 due to trocar injury. Soderstrom's study looked
retrospectively at 47 reported cases of major vessel injury resulting in successful litigation.
Such injuries were seven-times more likely to happen with a trocar.
It is worth remembering that in these studies, trocar injuries happened following insufflation –
the overall injury rate may, therefore, be even higher with direct entry.
Whatever the incidence, the treatment for a Veress needle bowel injury can usually be
managed conservatively with careful observation in hospital and antibiotics. Laparotomy is
mandatory for a trocar puncture. The bowel is most likely to be damaged when it becomes
adherent beneath the umbilical entry site.
A through-and-through injury.
The view through the laparoscope would be normal and give no indication of this perforation.
It is, therefore, necessary with this technique at completion of the procedure to withdraw the
laparoscope under direct vision to detect any through-and-through injury.
Further reading
The open technique described in 1971 by Hasson is gaining popularity, especially among
general surgeons. Basically, this is an intra-umbilical mini-laparotomy with a sealed cannula.
The peritoneal cavity is entered bluntly under direct vision.
Further reading
The risk of bowel damage after closed laparoscopy in the three most tightly controlled trials is
0.3 in 1000, and after open laparoscopy in the three best studies it is 0.4 in 1000. Even with
the large sample sizes, this is not significant.
A modified classic closed entry technique incorporates safety measures designed to minimise
all recognised complications.
This is based on the skin incision, the Veress insertion, the elevation of the abdominal wall,
insufflation to a pressure higher than that used for operating to splint the abdominal wall, and
once insufflation has occurred, correct positioning for trocar insertion.
Model answer
1. Palmers test
2. Insufflation test
Palmers test
A 10 ml syringe filled with normal saline is attached to the Veress needle. Aspiration is then
performed and absence of bowel content or blood suggests these structures have been
avoided.
Saline is then flushed through the cannula and there should be no resistance to flow.
Aspiration is then repeated and should only result in capture of saline if the tip of the needle is
within adhesions and the fluid has collected in a loculation.
Finally, as the syringe is disconnected the fluid level within the needle should be seen to drop
due to negative pressure in the peritoneal cavity.
Insufflation test
A high CO2 flow rate and low intra-abdominal pressure indicate correct placement as gas is
flowing freely into the peritoneal cavity. In practice, if the initial insufflation pressure is less
than 10 mmHg then the needle tip is invariably in the correct place.
The flow rate should approximate that noted at the initial test of the Veress needle function.
High pressures with a low flow rate suggests an incorrect position and the needle should be
withdrawn carefully without lateral movement.
Model answer
Model answer
The most common complication during secondary trocar insertion is injury to vessels of the
anterior abdominal wall:
Superficial vessels
Superficial circumflex iliac artery – a branch of the femoral artery passing below the inguinal
laigment then laterally towards the anterior superior iliac spine.
Superficial epigastric artery – also a branch of the femoral artery, crosses over the inguinal
ligament and is distributed towards the umbilicus.
Deep vessels
Inferior epigastric artery and vein – a branch of the external iliac artery medial to the deep
inguinal ring, passing superiorly behind the conjoint tendon to enter the rectus sheath behind
the muscle. A popular landmark is the obliterated umbilical artery or medial umbilical ford,
which passes medially to the inferior epigastric artery.
The position for secondary ports must, of course, be appropriately chosen to best facilitate
the particular operation being carried out, but also be safely away from important vessels. The
principal structure to be avoided is the inferior epigastric artery.
Key fact
It is an important basic principle of laparoscopic safety
that all secondary ports should be inserted and withdrawn
under direct vision.
List the differences between monopolar and bipolar diathermy in terms of how the current is
poroduced, transmitted and the effect on surrounding tissues.
Model answer
As the active electrode is small, there is a high current density and tissue effects occur
through heating. The return electrode has an area of approximately 150 cm 2 and, hence, very
low current density, so there is very little tissue heating.
Tissue damage may extend far from the point of contact and the extent of the damage is
related to the form of energy used. With monopolar current, energy preferentially dissipates
via vascular pathways. Although only a small serosal burn is evident, there may be a much
larger area of underlying devascularisation.
Bipolar electrosurgery involves using an instrument incorporating both an active and passive
electrode, usually some form of grasping forceps. Current flows only through the tissue held
between the paddles and there is consequently little surrounding necrosis.
The tissue between the instrument paddles does, however, become very hot, and power should
be only activated for the minimum time necessary to reduce risks from the thermal spread.
Watch the following videos of bipolar and monopolar diathermy. It is important that all
surgeons are familiar with the properties of energy sources. Operator error in relation to
electrosurgical equipment is more commonly responsible for bowel trauma than equipment
failure.
Model answer
Insulation failure
Consider the fact that 90% of the instrument is out of the surgeon's view. The characteristics
of electrical energy are such that unobserved damage may be occurring away from the active
tip.
All instruments must be regularly inspected for the integrity of the insulated shaft and, if the
desired effect is not evident, diathermy should be ceased immediately rather than blindly
calling for power to be increased. The surgeon's view shows no effect at the point of tissue
contact with the jaws of the forceps.
An unobserved bowel injury occurs as current grounds through a break in the insulation.
Direct coupling
It can be easy to unintentionally heat tissue close to the target. Imagine a loop of bowel very
close to a bleeding vessel. Its very proximity puts it at risk of damage as the vessel is
coagulated, especially if monopolar current is used.
Again, this is most likely where monopolar current is used, as the voltages required are high.
Any tissue that has become hot through diathermy should be allowed to cool before it comes
into contact with bowel. An example would be needle diathermy to polycystic ovaries, where
they retain heat for a considerable time and can cause a thermal burn to the bowel if allowed
to rest back in proximity.
Cooling can be facilitated by irrigation with saline via a suction or wash device.
Capacitance coupling
If this cannula is all-plastic it will not ground, but if it is all-metal it will allow current to
dissipate harmlessly over a wide area to the abdominal wall. The problem occurs with the
part-metal part-plastic cannulae, which will not dissipate the current away and may allow it to
ground in a high density fashion to the patient, causing a burn.
A second mechanism, which risks injury, occurs when the instruments are brought close
together within the peritoneal cavity. Current can transfer from the active electrode to, for
example, the telescope.
If the telescope lies within an all-metal cannula, then the current again dissipates harmlessly
to the abdominal wall. If a plastic cannula is used, however, it may ground in a high-density
fashion to bowel or other pelvic contents, causing a thermal burn.
Model answer
Do not include:
You note that one ovary is about 10 cm in diameter with an irregular outline, with mixed cystic
and solid components. There is ascites in the abdominal cavity.
Model answer
1. Diagnosis with a mixed cystic and solid mass has a high index of suspicion for
malignancy
2. Frozen section can be done prior to proceeding if this is available and ascites sampling
taken from the abdomen
3. Proceed to total hysterectomy and bilateral salpingooophorectomy and omentectomy
with palpation of the abdomen, peritoneum, liver and para-aortic nodes. This should ideally be
with the advice and discussion with the gynae-oncology team
4. Postoperatively, the patient needs debriefing on the findings and the resulting decision
to proceed and the operation that has been performed
5. The patient needs advice on the need for histological diagnosis and told the likely
timescale involved
6. If the histology is malignant, gynae-oncology referral is required. Arrange imaging and
biochemistry and tumour markers.
7. If the histology is benign no further treatment is required and she should be
commenced on HRT with the advice to use this to the age of about 50
Do not include:
History and investigation with biochemistry, imaging or tumour markers as these are
not relevant in this case
Avoiding oophorectomy in the absence of consent, or discussions on future fertility is
incorrect management
Risk identification - model answer
Think about possible means of risk identification in terms of internal and external sources.
Model answer
Internal sources:
External sources:
Model answer
A flowchart that can be used to guide clinicians when they are in doubt about how to deal with
young people who are sexually active can be found here: NHS Tayside Child Protection Policy,
2006.
Her recent Haemoglobin level was 8.1g/dL. Haematinics have confirmed iron-deficiency
anaemia.
Clinically Mrs Brown appears pale and a multifibroid uterus is palpated just above the
umbilicus.
After a long discussion, a hysterectomy is decided upon as the best course of action.
However, Mrs Brown mentions she is a Jehovah’s Witness and is adamant she would not
accept a blood transfusion under any circumstances.
Model Answer
Model Answer
The following issues should be taken in to consideration with this case study:
How would you fill out a death certificate for Mrs Brown?
In order to complete the death certificate, you will need the information below. Use your own
name and qualifications, but the hospital address shown.
Your address: C/O The Maternity Unit, Abersheen Maternity Hospital, Abersheen AB3 5WW.
Contacting the authorities about a death - model answer
List five circumstances where you would contact the authorities about a death.
abortion or miscarriage
accidents of any kind, however long before death they occurred
acute alcoholic poisoning
anaesthetic deaths
drugs, even when used therapeutically
industrial disease (a full list can be found in the certificate book)
medical mishaps/errors (death caused by an operative error/mishap must always be
reported). The death of a seriously ill person after a properly performed operation that was
part of the treatment must also be reported. Complaints by the bereaved would make it wise
to request postmortem examination via the Coroners Office
the death of a person in receipt of a war or industrial pension
poisoning of any kind
death of prisoners or anyone in custody
death occurring during or shortly after detention in police or prison custody
stillbirths if there is any doubt whether the child was born alive
the deceased was detained under the Mental Health Act
any local hospital admission/discharge rule
The Procurator will enquire into any sudden, suspicious, accidental, unexpected and
unexplained death. He or she may enquire into any death brought to his or her notice if it is
thought necessary to do so, especially where the evidence or circumstances suggest that the
death may fall into one or more of the following:
If you are in any doubt at all, lift the phone and discuss it either with the Coroner or the
Procurator Fiscal. Remember that the Procurator Fiscal will always be a lawyer; if the Coroner
is not a doctor, you will need to explain in terms that should be understandable to them.
Abortion Case Study - Model Answer
Faaiso Ali is 31 years old and is in her second pregnancy. She booked late at 17 weeks and
since then has been in Somalia. Faaiso is seen when she returns at 28 weeks pregnant. All
booking bloods are normal.
However, a detailed ultrasound scan has revealed the baby has anencephaly, which is
incompatible with extrauterine life. She is referred to the fetal medicine team who have
confirmed the diagnosis and prognosis.
She is very shocked by the findings and feels unable to make a decision about termination of
the pregnancy until she has discussed with her family. The idea of termination is not
completely rejected, however Faaiso does not want to regret her decision.
Model Answer
1. Termination of pregnancy (TOP) is covered by the Abortion Act (1991) and under clause
E TOP is possible at any stage of pregnancy if the fetal condition is incompatible with
extrauterine life
2. TOP should ideally be performed as soon as possible
3. Feticide would be required in this case as the pregnancy is more than 22 weeks
gestation
4. The patient and family (if the patient wishes) need to be fully counselled and time
given for all questions
5. If the patient decides against TOP routine antenatal care must continue.
HIV
A woman who is HIV positive is five months pregnant. She has not told her new partner that
she has HIV and does not want him to know. She claims that she is not having sex with him or
the father of the baby anymore.
She is on antiretroviral therapy and at delivery the baby will be due to receive the same. She is
not prepared to tell her partner of her status, despite all efforts by her obstetrician. She says
that she will make sure that the baby gets his therapy after the delivery. The consultant
paediatrician takes it upon himself to inform the partner without the woman's consent about
her status and without talking to her, because he believes that the partners' lack of
information will compromise the treatment for the baby.