PRACTICAL PROBLEMS INPRACTICAL PROBLEMS INLAPAROSCOPYLAPAROSCOPY

By Dr. RAMESH .BBy Dr. RAMESH .B

Anesthesia Problems

Equipment Problems

Electro Surgery Problems

Expertise Problems

Cost Problems

Inadequate Team

Antagonism

Inexperienced Assistant

Problems of Disposing

Disposables

Power Supply Problems

OR Setup Problems

Practical Problems

IntroductionIntroduction

Operative laparoscopy is an evolving field and Operative laparoscopy is an evolving field and

surgeons are new to this field and are still in the surgeons are new to this field and are still in the

process of acquiring and polishing their surgical process of acquiring and polishing their surgical

skills. Anything new poses challenging problems skills. Anything new poses challenging problems

and only time and experience can help one and only time and experience can help one

overcome them.overcome them.

OR Set Up

Equipment Problems

Laparoscopic Laparoscopic EquipmentEquipment

1.1. Assure table tilt Assure table tilt

mechanism is functional.mechanism is functional.

2.2. Consider using shoulder Consider using shoulder

brace and extra safety brace and extra safety

strap.strap.

3.3. Assure availability of Assure availability of

Foley catheter and N/G Foley catheter and N/G

tube.tube.

Preoperative Preoperative ConsiderationsConsiderations

4.4. Assure all power sources are Assure all power sources are connected and appropriate connected and appropriate units are switched "on" units are switched "on" (Don’t use multi-socket (Don’t use multi-socket single source or the circuit single source or the circuit will overload).will overload).

5.5. Assure adequate volume of Assure adequate volume of compressed gas (at compressed gas (at insufflator and pressure insufflator and pressure irrigator). Backup full tank irrigator). Backup full tank must be available.must be available.

6.6. Assure insufflator Assure insufflator alarm is set alarm is set appropriately. appropriately. Assure tight Assure tight connection between connection between insufflator tubing insufflator tubing and Luer-lock and Luer-lock adapter.adapter.

7.7. Assure full volume Assure full volume in irrigation fluid in irrigation fluid container (recheck container (recheck during case).during case).

8.8. Check the electrosurgical Check the electrosurgical unit; make sure auditory unit; make sure auditory alarm of machine is alarm of machine is functioning properly and functioning properly and the grounding pad is the grounding pad is appropriate for the appropriate for the patient.patient.

9.9. Check Veress needle for Check Veress needle for proper plunger/spring proper plunger/spring action and assure easy action and assure easy flushing through flushing through stopcock and/or needle stopcock and/or needle channel.channel.

10.10. Assure closed stopcocks Assure closed stopcocks on all ports.on all ports.

Excessive PressureRequired for Insufflations

Veress Veress needle or needle or cannula tip cannula tip not in free not in free peritoneal peritoneal cavitycavity

Reinsert Reinsert needle or needle or cannulacannula

Veress is inside, Veress is inside, but gas is not but gas is not flowing and flowing and pressure is high-pressure is high-

may be a piece of may be a piece of omentum is stuck –omentum is stuck –shake the shake the abdominal wall and abdominal wall and withdraw the withdraw the needleneedle

maybe the Veress is maybe the Veress is not patent- flush it not patent- flush it with saline to clear with saline to clear the channel.the channel.

Occlusion of Occlusion of tubing tubing (kinking, table (kinking, table joints, etc.)joints, etc.)

Port stopcock Port stopcock turned offturned off

Patient is Patient is “light”“light”

Inspect full Inspect full length of tubing. length of tubing. Replace with Replace with proper size as proper size as necessarynecessary

Fully open Fully open stopcockstopcock

Give more Give more muscle relaxantmuscle relaxant

Loss of Loss of PneumoperitoneuPneumoperitoneu

mm CO2 tank emptyCO2 tank empty

Accessory port Accessory port stopcock(s) notstopcock(s) not

properly properly adjustedadjusted

Leak in sealing Leak in sealing cap or stopcockcap or stopcock

Excessive Excessive suctioningsuctioning

Change tankChange tank

Inspect all Inspect all accessory accessory ports. Open ports. Open or close or close stopcock(s) stopcock(s) as neededas needed

Change cap Change cap or cannulaor cannula

Allow time to Allow time to reinsufflatereinsufflate

Tighten Tighten connectionsconnections

Replace or Replace or secure secure suturessutures

Connect Connect tubingtubing

Adjust Adjust flow rateflow rate

Loose connection Loose connection of insufflator of insufflator tubing at source tubing at source or at portor at port

Hasson stay Hasson stay sutures loosesutures loose

Tubing Tubing disconnection disconnection from insufflatorfrom insufflator

Flow rate set too Flow rate set too lowlow

EntryEntry 2)- Trocar- if 2)- Trocar- if

the the pneumoperitonpneumoperitoneum is lost eum is lost prior to prior to insertion due to insertion due to a deep incision-a deep incision-

Close the site Close the site with Allis, with Allis, create create pneumoperitonpneumoperitoneum from a eum from a different point, different point, preferably preferably Palmar’s and Palmar’s and introduce introduce trocar from the trocar from the primary site.primary site.

3)-Frequent 3)-Frequent slipping of 5mm slipping of 5mm trocars -trocars -

use a threaded use a threaded cannulacannula

If If extraperitoneal extraperitoneal insufflation insufflation occurs, occurs,

EntryEntry

let the gas escape let the gas escape and gain entry from and gain entry from the Palmar’ s point the Palmar’ s point which is a safe which is a safe alternative. This alternative. This point of insertion is point of insertion is also safe in a also safe in a patient with patient with multiple abdominal multiple abdominal incisions incisions

PositionPosition Position yourself well and the table must be at Position yourself well and the table must be at

the level of your elbow to ease the strain on the level of your elbow to ease the strain on the shoulder muscles.the shoulder muscles.

Position the patient well for vaginal Position the patient well for vaginal manipulation and free range of movements.manipulation and free range of movements.

VisionVision

1)Halogen lamp 1)Halogen lamp gives a yellow gives a yellow hue-hue-

2) Hazy picture-–2) Hazy picture-–to prevent a to prevent a hazy picturehazy picture

3) frequent 3) frequent foggingfogging

get used to it or get used to it or switch over to Xenonswitch over to Xenon

Focus your scope Focus your scope prior to entry prior to entry and properly and properly clean the lens clean the lens and the camera and the camera headheadfogging-clean fogging-clean the tip with the tip with Betadine / hot Betadine / hot salinesaline..

VisionVision 4)If the blood and 4)If the blood and

debris are debris are persistently persistently irritatingirritating

TIP-3 chip digital TIP-3 chip digital camera gives a camera gives a very good vision very good vision and a smooth and a smooth picture. A medical picture. A medical monitor prevents monitor prevents eye straineye strain

Flush the Flush the primary trocar primary trocar to clear any to clear any trickling blood trickling blood from the from the insertion site insertion site and then and then touch the tip touch the tip of the of the laparoscope laparoscope with irrigating with irrigating fluid on a fluid on a clean surfaceclean surface

Loose Loose connection at connection at source or source or scopescope

Bulb is burned Bulb is burned outout

Fiber optics Fiber optics are damagedare damaged

Adjust Adjust connectorconnector

Replace Replace bulbbulb

Replace Replace light cablelight cable

VisionVision Automatic iris Automatic iris

adjusting to adjusting to bright bright reflection from reflection from instrumentinstrument

Monitor Monitor brightness brightness turned downturned down

Room Room brightness brightness floods monitorsfloods monitors

Re-position Re-position instrumentsinstruments, ,

Readjust Readjust settingsetting

Dim room Dim room lightslights

Camera Camera control or control or other other components components (V.C.R., (V.C.R., printer, light printer, light source, source, monitor) not monitor) not “on”“on”

Cable Cable connector connector between between camera control camera control unit and/or unit and/or monitors not monitors not attached attached properlyproperly

Make sure all Make sure all power sources power sources are plugged in are plugged in and turned onand turned on

Cable should Cable should run from “video run from “video out” on camera out” on camera control unit to control unit to “video in” on “video in” on primary primary monitor. Use monitor. Use compatible compatible cables for cables for camera unit and camera unit and light source.light source.

VISIONVISION

foggingfogging Condensation on lens from cold Condensation on lens from cold scope on entering warm scope on entering warm abdomenabdomen

Wipe lens on viscera with Wipe lens on viscera with warm salinewarm saline

Cold gas Cold gas Use ThermoflatorsUse Thermoflators

Condensation on scope Condensation on scope eyepiece, camera lenseyepiece, camera lens

Detach camera from scope Detach camera from scope and clean lensand clean lens

Flickering, Flickering, electrical electrical interferenceinterference

Moisture in camera cable Moisture in camera cable connecting plugconnecting plug

Poor cable sheildingPoor cable sheilding

Insecure connection of video Insecure connection of video cable b/n monitorscable b/n monitors

Use suction or compressed Use suction or compressed air to dry out moistureair to dry out moisture

Replace cables as necessary Replace cables as necessary and move ESU away from and move ESU away from video equipmentvideo equipment

Reattach video cable at each Reattach video cable at each monitormonitor

Blurring, Blurring, distortiondistortion

Incorrect focusIncorrect focus

Cracked lens, internal moistureCracked lens, internal moisture

Too grainyToo grainy

Focus the cameraFocus the camera

Inspect scope/camera sos Inspect scope/camera sos replacereplace

Adjust enhancements or Adjust enhancements or grain settings grain settings

Suction / IrrigationSuction / Irrigation

Occlusion of Occlusion of tubing tubing (kinking, (kinking, blood clot, blood clot, etc.)etc.)

Occlusion of Occlusion of valves in valves in suction/irrigasuction/irrigator devicetor device

Inspect full Inspect full length of tubing. length of tubing. If necessary, If necessary, detach from detach from instrument and instrument and flush tubing with flush tubing with sterile salinesterile saline

Detach tubing, Detach tubing, flush device with flush device with sterile salinesterile saline

Suction / IrrigationSuction / Irrigation

Not attached to Not attached to wall wall suction/machinsuction/machinee

Irrigation fluid Irrigation fluid container not container not pressurizedpressurized

Inspect and secure Inspect and secure suction & wall suction & wall source connectorsource connector

Inspect compressed Inspect compressed gas source, gas source, connector, pressure connector, pressure dial settingdial setting

Expertise Expertise ProblemsProblems

HAND EYE HAND EYE COORDINATIONCOORDINATION Surgeon must develop good hand Surgeon must develop good hand

eye coordination before eye coordination before attempting any laparoscopic attempting any laparoscopic surgery by constant practice on surgery by constant practice on the pelvi Trainer.the pelvi Trainer.

Camera HoldingCamera Holding Assistant should stand on the Rt Assistant should stand on the Rt

side of the Patient and be an side of the Patient and be an expert at holding the camera & expert at holding the camera & must anticipate the next steps of must anticipate the next steps of the surgery helping the smooth the surgery helping the smooth progression.progression.

Operative Operative Techniques-Techniques-

Large Uteri-Large Uteri- Position the primary and Position the primary and

lateral ports higher.lateral ports higher.

Use your ports efficiently Use your ports efficiently along with a good vaginal along with a good vaginal manipulator with patient’s manipulator with patient’s buttocks protruding buttocks protruding beyond the edge of the beyond the edge of the table to give traction table to give traction counter traction to make counter traction to make the structures more taut the structures more taut so that cauterization and so that cauterization and dissection or cutting dissection or cutting becomes easy. becomes easy.

Myoma screw is very Myoma screw is very helpful for traction.helpful for traction.

Creation Of Creation Of PlanesPlanes

While pushing the UV While pushing the UV fold-fold-

try coming from the lateral try coming from the lateral edges towards the centreedges towards the centre

If you still don’t happen to get If you still don’t happen to get the plane- convert TLH to the plane- convert TLH to LAVHLAVH

In Adhesiolysis –In Adhesiolysis – Always start from the normal Always start from the normal

anatomy and proceed towads anatomy and proceed towads the abnormal as the planes the abnormal as the planes open up.open up.

Use harmonic as the Use harmonic as the cavitational effect will help cavitational effect will help the creation of planes.the creation of planes.

Operative Operative Techniques-Techniques-

Intra operative bleeding-Intra operative bleeding- Always cut less and cauterize more Always cut less and cauterize more If at all bleeding occurs- first see-don If at all bleeding occurs- first see-don

t comprise on vision-by repeated t comprise on vision-by repeated suction irrigation-isolate the bleeder suction irrigation-isolate the bleeder and coagulateand coagulate

Tissue RetrievelTissue Retrievel

CLOTS in Ectopic CLOTS in Ectopic pregnancypregnancy

Spoon forcepsSpoon forceps High pressure irrigation and High pressure irrigation and

suctionsuction 10mm suction cannula10mm suction cannula ColpotomyColpotomy EndobagEndobag

Tissue RetrievelTissue Retrievel Removal of Removal of

degenerated degenerated fibroids like cystic fibroids like cystic , calcified fibroids , calcified fibroids are difficult toare difficult to morcellatemorcellate

colpotomy colpotomy is a better is a better optionoption..

If the myoma If the myoma screw breaks screw breaks during the during the enucleation of the enucleation of the fibroid. fibroid.

- - remove the broken remove the broken piece as it may piece as it may damage the damage the morcellator blade if it morcellator blade if it touches the blade touches the blade during morcellationduring morcellation

Loss of Loss of Pneumoperitoneum after Pneumoperitoneum after

ColpotomyColpotomy Use uterus as a Use uterus as a

pneumo occluderpneumo occluder Ceanna Glove- Ceanna Glove-

wet sponge in a wet sponge in a glove as a glove as a pneumo pneumo occluder.occluder.

Various Various manipulators manipulators with inbuilt with inbuilt pneumo-pneumo-occluders.occluders.

EndosuturingEndosuturing

Practice makes Practice makes one perfectone perfect

Use short length Use short length of suture of suture materialmaterial

Electro Surgical Electro Surgical UnitsUnits

Patient not Patient not grounded grounded properlyproperly

Connection Connection between between electro-electro-surgical unit surgical unit and instrument and instrument looseloose

Foot pedal or Foot pedal or hand switch hand switch not connected not connected to to electrosurgical electrosurgical unitunit

Assure Assure adequate adequate return return pad pad contactcontact

Inspect Inspect both both connectinconnecting pointsg points

Make Make connectioconnectionn

ELECTRO-SURGICAL UNITELECTRO-SURGICAL UNIT

Wrong output Wrong output selectedselected

Connected to Connected to the wrong the wrong socket on the socket on the electrosurgical electrosurgical unitunit

Instrument Instrument insulation insulation failure outside failure outside of surgeon’s of surgeon’s viewview

Correct output Correct output choicechoice

Check that Check that cable is cable is attached to attached to proper socketproper socket

Use new Use new instrument and instrument and inspect inspect insulationinsulation

Electrosurgical Electrosurgical UnitUnit

Cautery Cautery smoke smoke obscures obscures visionvision

If Bipolar If Bipolar is not is not working, working,

-do suction and -do suction and remove the remove the smoke, instead smoke, instead of opening the of opening the vent of the vent of the trocar as it will trocar as it will prevent prevent inhalationinhalation

for coagulation for coagulation use monopolar use monopolar thermocoagulatithermocoagulationon

Electro Surgical Electro Surgical UnitUnit

Lateral spread-use harmonic when Lateral spread-use harmonic when close to vital structures or sharp close to vital structures or sharp dissection with scissorsdissection with scissors

Use bipolar whenever appropriateUse bipolar whenever appropriate Coagulate with cutting current as it Coagulate with cutting current as it

is low voltageis low voltage

Antagonism From Antagonism From Fellow Fellow

GynaecologistsGynaecologists

N2O causes bowel distention- N2O causes bowel distention- switch to mixture of O2 and Airswitch to mixture of O2 and Air

Switch over to sevoflurane for Switch over to sevoflurane for smooth recoverysmooth recovery

Problems Caused Problems Caused by Anaesthetiaby Anaesthetia

Financial ProblemsFinancial Problems

Costly equipmentsCostly equipments TackersTackers MeshMesh

CONCLUSIONCONCLUSION

Patience and persistence can help you Patience and persistence can help you master the laparoscopic surgical master the laparoscopic surgical technique. Efficiency increases with technique. Efficiency increases with experience and remember it is a team experience and remember it is a team effort and first build a good ground effort and first build a good ground support team and train them well.support team and train them well.

THANK U FOR A PATIENT THANK U FOR A PATIENT HEARINGHEARING