AGENDA. OR Equipment Entery Anatomy Videos Trics and Tips Closure Limitations to endoscopy 2012??

Transcription

1 BASIC LAPAROSCOPY Olav Istre MD, DMSc. Head of Gynecology Aleris-Hamlet Hospital, Scandinavia Professor in Minimal Invasive Gynecology University of Southern Denmark

2 SUCCESFUL ENDOSCOPY Operating rooms Equipment Dedicated nursing staff Smooth hospital enviroment A ` nurd ` Doctor burning for it, Training, training, suturing suturing Low complication rate Good follow up and control of data Satisfied patients

3 ½ Basic Instruments

4 EQUIPMENT Verres canula or Single port cannula Optic 5 mm, 30 degree, High Definition(HD) Able for port jumping Change angle (flex scope), special good for single port Big fibroids Difficult endometriosis Coming around the corners Craspers and cutting device Bipolar Ultra Sound, thunderbeat (combined ultrasound and bipolar) scissors

5 AGENDA OR Equipment Entery Anatomy Videos Trics and Tips Closure Limitations to endoscopy 2012??

6 Entery with Verres needle

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8 First incision cut upwards Call for a laparotomy kit. If need be open the patient immediately using a midline incision and put pressure on the bleeder and/or aorta Call for help Call for blood products Call for vascular surgery or a general surgeon Notify anesthesia immediately Do not panic Do not freeze

9 Favorable outcome, IF they are recognized intraoperatively Mechanical bowel preparation. No improvement in prognosis in the colorectal literature) Mechanical bowel preparation does not improve visibility during laparoscopy MBP does significantly increase patient discomfort, dehydration, nausea, vomiting and abdominal discomfort Obstet Gynecol. 2011;4(1):28-31 doi: Bowel injuries, use umbilical ultrasound pre op

10 During surgery, use 4 hands, and nurse handling the uterine manipulator

11 PORT PLACMENT WORKING CONDITION FOR LARGE UTERI/FIBROIDS

12 ANATOMY Ability to construct a three dimensional view. Knowledge of basic anatomic layout Necessary 16/03/

13 UTEROSACRAL POD Rectum URETER DR.SHAILESH PUNTAMBEKAR 16/03/

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15 Ureter Internal Iliac artery Obliterated hypogastric a External Iliac Vein & Artery DR.SHAILESH PUNTAMBEKAR 16/03/

16 What can be done Any Limit?? Fibroids hysterectomy Big cysts Pregnancy Cerclage Oncology Urogynecology Prolaps Sacrokolpopexy TVT

17 Hysterectomy in Denmark, Acta Scand Gyn Obst 90,2011,

18 HOW TO AVOID LAPAROTOMY DOING LAPAROSCOPIC HYSTERECTOMY, A CONSECUTIVE STUDY OF 160 HYSTERECTOMIES Background: Abdominal hysterectomy TAH is the main treatment for enlarged uterus in Denmark 53%. Laparoscopic hysterectomy is performed in 12% Vaginal route is utilized in 35% in the smaller uterus Complication rate 18% Readmission rate 5,4% Repeat surgery 4% The Danish Hysterectomy database 2010

19 Design Consecutive patient No rejection of referred patient From Gynecological specialist Government hospitals waiting list From insurance companies Private referral's 100% laparoscopic approach, apart from vaginal hysterectomy

20 PATIENTS EXPECTATION PRIOR TO HYSTERECTOMY Interview of 100 patients 33 % anticipated laparoscopic hysterectomy Is Laparoscpic hysterectomy better?? 89% much better 6% better 5% indifferent Satisfaction rate with laparoscopic produre 9,5 in a scale 0-10

21 INTRODUCTION OF LAPAROSCOPIC HYSTERECTOMY IN A PRIVATE SETTING IN DENMARK, N=150 YEAR 2011 LSH N=82 BMI=24 Age 47 TLH N=46 BMI=25 Age 46 Vag Hyst N=19 BMI=25 Age 61 OR time 76 (35-175) 78(35-150) 84(50-120) 78 Grams 352( ) 257(56-950) (42-79) 301 Bleeding 86(5-800) 61(10-300) 68(20-200) 81 Tot Normal activity(days) 5 (1-14) 5(1-14) 6(1-14) 5.5 Back to work 14(1-42) 17(7-35) 24(14-49) 16 Postop Complcation N=100 4 (5%) 2(4,2%) 1 7

22 COMPLICATIONS 7/100 Perioperative complication One bladder trauma, laparoscopic primary treatment Postoperative complications( first 100 with 3 mnt follow-up) One ureter lesion repeared lapscopically 3 w postop 4 infections treated with AB 2 readmitted One scar infection One haematoma (VH)

23 ONE LAPAROTOMY CONVERSION 1/160 CONCEQUTIVE PATIENTS

24 CLOSSURE OF THE VAGINAL CUFF DURING TLH Skeletonize uterine artery Incision on the uterine manipulator Use barbed suture (Keeps the tension) Start anterior (Better control of bladder) Suture in 2 Layers Used modified McCall suspension

25 UTERINE MAINIPULATOR AND VAG CUFF HOLDER DURING VAGINAL SUTUR The Ellec evacuator

26 CLOSURE OF PORTS Close mm Severral times in and out PDS sutur Internal or outside facie closure

27 PORT COMPLICATIONS

28 POST OPERATIVE CLOSURE Waterproof and aplication of vacum Aquacel and Tegaderm

29 Thanks for your attention