GENERAL INTRAOPERATIVE PRINCIPLES

GENERAL INTRAOPERATIVE PRINCIPLES

Many minimal access procedures have a unique set of proce - dural steps that may often be in a distinctly di ff erent sequence from those of the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of surgical scars and potential for perivisceral adhesions. In the setting of redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of some of the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ). GENERAL INTRAOPERATIVE PRINCIPLES

Many minimal access procedures have a unique set of proce - dural steps that may often be in a distinctly di ff erent sequence from those of the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of surgical scars and potential for perivisceral adhesions. In the setting of redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of some of the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ). GENERAL INTRAOPERATIVE PRINCIPLES

Many minimal access procedures have a unique set of proce - dural steps that may often be in a distinctly di ff erent sequence from those of the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of surgical scars and potential for perivisceral adhesions. In the setting of redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of some of the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ).