Port Placement For Laparoscopic Orchiopexy - PowerPoint Presentation

Slide1

Port Placement For Laparoscopic Orchiopexy

1. PREPARATIONS

1. Re-examine patient under anesthesia

- confirm that testicle is

nonpalpable

and diagnostic

laparoscopy is necessary

- ready lap instruments

2. Position & prep patient

Position

supine with arms tucked, legs spread apart , pressure points padded, and patient secured at chest with tape. Clean umbilicus well prior to prep with Q-tips and alcohol. Betadine Prep

Xyphoid

down to scrotum, and laterally to include inguinal canals.

3. Place Foley  & NG/OGT

Place

appropriate sized Foley on field to empty

bladder, and request NG/OG

placement from anesthesia

(bedside drainage bag to anesthesiologist)

4. Mark camera port site

Inferior border of umbilicus is marked. Using

toothed Adson forceps the umbilicus is everted. A vertical

skin

mark

is made at midline along

umbilicus.

Mark does not extend beyond previously marked inferior limit.

2. INCISIONS

1. Superficial skin

Incise with 11 blade

through skin and dermis.

2. Deepen incision

Surgeon and assistant grasp and elevate edges of incision.

Electrocautery

or cold knife is used to

deepen incision to fascia (through dermis and

subq

fat)

3. Expose fascia and incise

Hemostat used to spread deeper to reach

fascia. Fascia

is lifted up and incised under vision.

4. Fascial Stay Sutures.

Fascial

edges

are grasped

using toothed pick ups (e.g., Adson).

A

Vicryl

(2-0) is placed vertically

on each side of fascia.

5. Identify peritoneum and intraperitoneal access

With upward traction on stay sutures a hemostat is used to verify

entry into peritoneum. If peritoneum remains intact, incise to allow passage of a 5 mm STEP sheath with

Veress

needle

3. INSUFFLATION

1.

Veress

Needle

Placement with drop test

With upward traction

on stay sutures, a

5 mm

STEP port sheath with

Veress needle

is introduced under vision into peritoneal cavity.

A 10 mL syringe filled with 6 mL saline is used to

aspirate .

There should be bubbles but

no return of

succus

or blood.

2 mL saline is injected into port with liquid visible at lock. Syringe is removed and peritoneal access is verified with fluid dropping under gravity.

2. Turn on CO2 gas flow &

connect to Veress

needle 

Set

pressure and flow.

Pressure 8-10 mm Hg.

Flow: 1 Liter/min.

Prior to connecting tubing check gas is flowing from tubing, and insufflation valve is open.

Alert anesthesia that you will begin insufflation.

Connect gas to port. O

bserve opening

pressure s.

Pressure should be

<5mm Hg. I

f pressure >5mm Hg manipulate Veress by withdrawing slightly (e.g., it may be up against bowel or omentum). If pressure remains high,

disconnect gas and redo Veress Needle insertion.

3. Pneumoperitoneum

As abdomen fills, confirm

pneumoperitoneum

is equal by percussing all four

quadrants.

4. Complete CO2 filling

Fill to total pressure of 8-10

mm Hg.

I

n larger

children

12mm

Hg may be used.

 Increased

pressure can compromise cardiopulmonary dynamics and there should be an open line of communication with anesthesia

4

VISUALIZATION

1. Place camera port

Veress

needle is removed from the STEP sheath and a finger is placed over the hole to prevent egress of gas. A 5 mm port is then introduced into the sheath.

2. Place camera

A

5 mm lens and camera are placed into the port and used to in

spect for intrabdominal injury

- Position patient

in Trendelenberg if needed to obtain better vision

drops intestine away

3. Diagnostic laparoscopy

-

i

nspect abdominal wall, intestines,

rectum, and bladder

- assess for any anomalies (e.g., persistent

Mullerian

ducts)

- evaluate

both

internal rings

- identify status of vessels and vas. If you find:

vessels are blind-ending or cord is visualized going into the ring

-

omit placing

other ports

intrabdominal testicle requiring

pexy

, atrophic/dysmorphic testicle requiring orchiectomy, or further dissection to explore for a testicle (reflecting colon to explore retroperitoneum then proceed to place additional ports.

5.

PLACE ANCILLARY PORTS

1. Mark lateral port sites

STEP ports (

3

or 5 mm) are

used for additional ports. If cautery or clips will be used then 5 mm port is necessary. M

ark incision

approximately one

fingerbreath

below the camera port and 4

fingerbreaths

lateral to camera port. During planning ensure they are away from epigastric vessels.

2. Port site

: Superficial

skin incision

Use

a #15 blade

scalpel

to incise skin and dermis. D

eepen incision with

Bovie

.

Use a

hemostat to spread

to fascia.

3. Penetrate

fascia

Use

a

bovie

to

penetrate

fascia and peritoneum under laparoscopic vision.

4. Place lateral port

Once this tract is made a STEP sheath with

Veress

is passed under vision into the peritoneal cavity

through established tract.

Veress

is removed from sheath and a 3 or 5 mm port is placed into the sheath under laparoscopic vision

Repeat on other side