How to prepare a patient for laparoscopy ?

FOR LAPAROSCOPY

MAHMOUD ABDELALEEM

Preparation of a patient

INTRODUCTION

The field of endoscopic surgery has expanded dramatically in the last 25 years.

Laparoscopy is the accepted treatment modality for many gynaecological conditions.

Advantages of laparoscopic surgery extend to include patient, surgeon and health system.

Patient

Team

Surgeon

OR

IMPORTANT RULES

Safety comes first……….!!! Looking through a hole Magnified field Although Any operation can be done by

LAPAROSCOPY, Not every GYNECOLOGIST should be competent in laparoscopic surgery !!!! This is a highly technical subspecialty.

Valid indication in the absence of contraindication with every possible step to avoid complication.

Two years before •Prepare yourself, your team and the OR.

One week before•Indication.•Contraindication.•Counseling.•Timing

One day before •Patient instructions.

Day “0” •Check the OR.•Check the team.

TWO YEARS BEFROE

Prepare your self by knowledge, skills and competence in open surgery.

Prepare yourself to be a laparoscopic surgeon: Develop eyes-hands-foot coordination by Being a good Wii player. Stick to a competent laparoscopic surgeon to observe then perform under

supervision then perform alone then train others. 4-7 years are required to attain good experience.

Always attend courses, workshops, use pelvi-trainer exercises, use virtual reality simulators, and watch video films.

Prepare an experienced anesthesiologist.

Prepare a well-designed OR for laparoscopy.

Build up a team for laparoscopic surgery.

Two years before •Prepare yourself, your team and the OR.

One week before•Indication.•Contraindication.•Counseling.•Timing

One day before •Patient instructions.

Day “0” •Check the OR.•Check the team.

THE WEEK BEFORE

The indication. The contraindication. The counseling.

Realistic expectations. Patient awareness.

Timing: Never during menses. Best in the postmenstrual phase. Premenstrual ??????

Treat any lower genital tract infection.

DIAGNOSTIC LAPAROSCOPY

Infertility. Pelvic pain: acute and chronic. Missed IUD. Undisturbed ectopic pregnancy. Suspected PID.

PCOS

Failed induction in an infertile patient. PCOS is a medical disease

Lean patient. LH > 10 IU/L. Hyperandrogenism. Not small sized ovaries. Other fertility factors normal. Regular marital life 6 months after the operation should be

guaranteed. Counsel that patient that this line is effective only in half the

patients. Every effort to avoid reduced ovarian reserve. Every effort to avoid postoperative adhesions.

PELVIC ADHESIOLYSIS

Aim at both patency [anatom] and potency [physiolo] of the tube. PATENCY: HSG, chromopertubation, sonosalpingography POTENCY: HSG !!!, salpingoscopy. Safe adhesiolysis Always remember the rule of 6

Do the procedure day 6-10 postmenstural. 6 eyes: “3” surgeons should decide whether to do or not to do. When ooze occurs apply pressure for at least 6 minutes. If not pregnant within 6 months: ART is an option. Always fill the DP by about 600 mL of saline at the end of

procedure.

OVARIAN CYST

Every possible step to avoid: A cyst that would disappear spontaneously

!!!!! A cyst that would bring up more

complications!!!!! Malignant cyst. Dermoid cyst.

Every effort to avoid reduced ovarian reserve.

Every effort to avoid postoperative adhesions.

PREOPERATIVE EVALUATION

The goal of preoperative evaluation is to identify and modify risk factors that might adversely effect anesthetic care and surgical outcome.

Up to 50% of patients presenting for elective surgery are regarded as “healthy.”

A patient presenting without established medical diagnoses is not necessarily healthy

Preoperative evaluation should seek to determine absolute contraindications to laparoscopy. Poor risk for general anesthesia Inability to tolerate pneumoperitoneum Uncorrectable coagulopathy

History of cardiopulmonary disease

Risk of pregnancy History of previous abdominal

operations History of abnormal bleeding Difficulty with prior anesthetics

Assessment of the head and neck Assessment of lungs and heart. Assessment of the abdomen

(including surgical scars). Assessment of neurologic &

vascular systems. Vital signs.

Diagnostic studies should be performed on a selective basis.

Hemoglobin (Hg): Indicated if significant blood loss may be expected from the operation. Anemia may be sought in women with heavy menstrual bleeding.

Coagulation profile: While routine screening is not useful, PT and PTT should be checked in patients with a personal or family history of abnormal bleeding.

Serum electrolytes: Routinely check electrolytes, blood urea nitrogen (BUN), and creatinine for patients with diarrhea, renal disease, liver disease, or diabetes as well as for those receiving diuretics.

Liver function tests are indicated for patients with known liver disease.

Chest X-ray (CXR): Routine CXR is rarely helpful for abdominal laparoscopy,

Electrocardiogram (EKG): reserved for women older than 50, particularly those with other risk factors such as Hypertension, obesity, or diabetes.

Pregnancy test: Indicated in female patients of childbearing age.

Human immunodeficiency virus (HIV) and hepatitis testing is not indicated.

Two years before •Prepare yourself, your team and the OR.

One week before•Indication.•Contraindication.•Counseling.•Timing

One day before •Patient instructions.

Day “0” •Check the OR.•Check the team.

THE DAY BEFORE (DAY -1) Inform an experienced anesthesiologist. Tell the patient to have full fasting for 8 hours. Patient should clean her umbilicus and panniculus well. If expecting difficult adhesiolysis, bowel preparation is done. Management of patients’ baseline medications and special

surgery-related medications as well as day of surgery instructions

Sleep well !!!!!!.

TAKE CARE: Ergonomic study among laparoscopic surgeons showed 87% experienced musculoskeletal symptoms (neck ache, back pain, elbow pain, wrist pain and finger numbness) occasionally or often during their operating sessions, and 59% experienced neurological symptoms (headache and eyestrain) occasionally or often.

Two years before •Prepare yourself, your team and the OR.

One week before•Indication.•Contraindication.•Counseling.•Timing

One day before •Patient instructions.

Day “0” •Check the OR.•Check the team.

THE DAY OF SURGERY DAY (0)

Consent and documentation. Check for instrumentation before patient gets in.

Any failure counts only against you. !!!!!!! Be near to a conventional surgery theatre -just in

case- !!! IV 1gm of prophylactic antibiotic 0.5 hour before

anesthesia. To be repeated at one hour interval during surgery.

Put in mind the concept of anticoagulation if surgery lasts > 30 minutes. Extended laparoscopic surgery is classified as moderate risk.

OBESE PATIENT There is no absolute contraindication. Additional preoperative testing/information:

EKG, CXR, Attempted weight loss preoperatively, even if minimal, Cardiac and pulmonary testing as indicated in those with cardiac or pulmonary comorbidities.

Special issues for the informed consent: Increased chance of conversion to open laparotomy. Additional ports may be required to obtain

adequate exposure. Prepare Extralong ports, trocars, and

instruments may be needed.

Additional preoperative medical/anesthesia planning: Standard risk evaluation should be performed. Complete muscle relaxation. The degree to which the abdominal

wall is elevated in response to the pneumoperitoneum is maximized if the abdominal wall muscles are relaxed.

Unique OR equipment or staffing: Increased OR time. Laparoscopic surgery in the morbidly obese

patient often requires additional OR time. Special large-size OR table. Foot boards and safety straps to avoid shifting during

intraoperative positioning. Special instruments. Additional ports for exposure. Postoperative “Big Boy Bed.”

PREGNANT PATIENT

The pregnant patient may develop appendicitis, cholecystitis, torsion of the ovary, or a number of other problems that may require urgent or emergent surgery.

Due to an increased risk of preterm delivery (<37 weeks estimated gestational age), every effort should be made to postpone surgery until after delivery of the fetus, except for emergent indications.

When surgery is necessary in this population, minimally invasive methods can be used.

Most authorities recommend avoidance of pneumoperitoneum and laparoscopy until the second trimester for indicated nonemergent operations.

It is important to avoid manipulation of the uterus during surgery, which can induce preterm labor.

Additional preoperative medical/anesthesia planning: Avoid fetal acidosis. Keep end-tidal CO2 between 25 and 33 by changing minute

ventilation. Consider arterial blood gas monitoring. Special anesthetic precautions should be used to avoid

aspiration and hypotension. Special issues for the informed consent:

Increased chance of conversion to open laparotomy. The risks relating to surgery during the first trimester include

teratogenesis and a miscarriage rate of approximately 12%. The possibility of damaging the gravid uterus with

laparoscopic instruments, ports, or trocars.

Planned alterations from the standard laparoscopic approach: Minimize operative time so that fetal acidosis is

minimized. Solicit the most senior assistant available even for a

“minor” case. Minimize pneumoperitoneum pressures to the 10–

12mmHg level. Elevation of the patient’s right side during positioning

to avoid inferior vena cava compression by the gravid uterus.

Use angled laparoscopes to facilitate seeing around the uterus.

Maternal monitoring with end-tidal CO2

WISHING YOUHAPPY AND SUCCESSFUL

LAPAROSOCPIC PROCEDURE

THANK YOU