Chapter 11
Preparing for Surgery
Abdominal wall preparation
Abdominal wall preparation should embrace a rectangular area the borders of which extend from the xyphisternum to the pubic symphysis and from one anterior superior iliac spine to the other. The usual principles of skin antisepsis are followed. Towels are placed in a manner such that the rectangular area of exposure is maintained. Special attention is given to cleaning the umbilicus.
General comments
Prior to the induction of anesthesia, the surgeon must ensure that all the ancillary equipment is present and functioning. This includes the endovision camera, CO2 cylinder (sufficient quantity of gas for the planned procedure), bipolar machine, light source, and electrosurgical generator. It is not safe to anesthetize the patient if any of the necessary accessory machines are faulty or non-functioning immediately prior to initiation of the operation.
The preparation at the vaginal aspect of the operative field will have included insertion of a Foley catheter into the bladder, placing the patient into the Lloyd-Davies (frog leg) position, cervical dilatation up to #9 Hegar and insertion of the Sankpal uterine manipulator into the uterus through the endocervical canal.
Once the patient is anesthetized, the following actions must be taken before introduction of the primary trocar: all the necessary accessories required to accomplish the laparoscopic hysterectomy are arranged on the patient’s abdomen in a ready to use manner. These include endovision camera head connected to the eyepiece of the telescope, fiber optic light cable connected to the telescope and the light source, bipolar cord connected to the electrosurgical generator, irrigation cannula connected to the irrigation fluid bag, and suction tubing connected to the suction machine. The foot switch is placed next to the surgeon’s foot in an easily accessible and ready to operate position. At this point, the surgeon should make a mental note of the set pressure and the flow rate of the CO2 insufflator, the electrosurgical generator settings and the patient’s baseline vital parameters. In addition, one should ensure that the autostart button (present on the majority of modern bipolar machines) on the bipolar machine is in the off position prior to the start of surgery. Not to do so will allow immediate flow of electricity once the bipolar forceps comes in contact with any tissue, even without activating the foot pedal. If this format is followed, all will proceed easily after the primary trocar is placed.
With the patient properly placed on the table (see above) and prior to inserting the primary port, it is necessary to inspect and palpate the abdomen for the following: stomach distension, uterine height, presence of scars and distended bladder. If the stomach is distended, distension can be diminished by pressure on the stomach or insertion of a nasogastric tube. If the bladder is distended in the presence of a Foley catheter, the scrub nurse should be instructed to check the catheter to rule out any obstruction.
The abdominal preparations will have included placing the arms by the patient’s side with IV extension tubing under the covering cloth. If the surgeon is comfortable with direct trocar entry, the primary port can be placed by lifting the abdominal wall with the assistant surgeon and direct trocar insertion at the selected site. In other instances, pneumoperitoneum can be established in the traditional manner using the Veress needle. Either method is acceptable. However, neither method is risk free if the trocar is placed at an improper angle or pushed too far. For example, with direct insertion it is only necessary to push the trocar tip through the skin, fascia, and the peritoneum. Only the tip should penetrate the peritoneum and the trocar should not be pushed beyond this level. The insertion of the trocar has one and only one function, i.e. to provide a path for the laparoscope itself. As such, the tip of the trocar only makes an opening. In this manner, one can enter the abdomen in relative safety even with direct trocar entry. It is not the size of the instrument, but the technique of insertion that causes damage. With experience, the surgeon can obtain the tactile sensation of the path of the primary trocar.