how to prepare a patient for laparoscopy?

1. Preparation of a patient
FOR LAPAROSCOPY
MAHMOUD ABDELALEEM

2. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. DIAGNOSTIC LAPAROSCOPY
 Infertility.
 Pelvic pain: acute and chronic.
 Missed IUD.
 Undisturbed ectopic pregnancy.
 Suspected PID.

10. 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.

11. 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.

13. 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.

14. 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

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

16.  History of cardiopulmonary disease
 Risk of pregnancy
 History of previous abdominal operations
 History of abnormal bleeding
 Difficulty with prior anesthetics

17.  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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24.  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.”

25. 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.

26.  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.

27.  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

28. WISHING YOU
HAPPY AND SUCCESSFUL LAPAROSOCPIC
PROCEDURE
THANK YOU