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FLS Module 3 - basic laparoscopic
procedures – QUESTIONS WITH
ANSWERS
What are some of the newest developments in laparoscopic surgery? - CORRECT ANSWERS ✔✔Robotic assistance, single port site procedures, Natural Orifice Translumenal Endoscopic Surgery (NOTES), and intrauterine fetal surgery List 5 laparoscopic procedures that are performed on newborn infants - CORRECT ANSWERS ✔✔appendectomy, undescended testes, anti-reflux surgery, pectus repair, PDA, intestinal atresia, pyloromyotomy, and surgery for Hirschsprung's disease Indications for diagnostic laparoscopy - CORRECT ANSWERS ✔✔elective - cancer staging, chronic abdominal pain urgent - small bowel obstruction, vs ileus Emergent - trauma, suspected iatrogenic injury, perforated viscous During what procedures could you inadvertently enter the peritoneal cavity and subsquently need to perform a
diagnostic laparoscopy? - CORRECT ANSWERS ✔✔hysteroscopy, endoscopy Key elements of performing a lysis of adhesions - CORRECT ANSWERS ✔✔Use both blunt and sharp dissection with gentle traction on tissue. Be cautious and sparingly use energy sources for hemostasis to avoid thermal spread What is the best position for patients getting surgery on the upper abdomen? - CORRECT ANSWERS ✔✔Arms on arm boards, reverse trendelenburg position with a footboard and safety strap on lower thighs to keep patient from sliding. Monitors placed at head of table for viewing operative field. What is the key to patient positioning? Where would you place your initial port for a diagnostic lap where you need to view the entire abdomen? After your initial port, where do you place additional ones? - CORRECT ANSWERS ✔✔Maximize the ergonomics of the surgeon and assistant. Usually initiate access in LUQ and 2 additional ports can also be placed in the left abdomen (then surgeon and assistant can stand on left side together). This allows the entire abdomen to be visualized except for immediately below the ports or lateral to the ports.
- Retract uterus with manipulator or suture retraction to the abdominal wall. Diagnostic lap for suspected appendicitis - CORRECT ANSWERS ✔✔- Left arm tucked, allowing surgeon and assistant to stand on left side.
- T-burg
- Rotate slightly to a "right side up" orientation
- Secure patient adequately to table What are the anatomic landmarks or the beginning and end of the small bowel? - CORRECT ANSWERS ✔✔LUQ at ligament of Treitz to RLQ at ileocecal valve Why would you want to have 2 monitors for a diagnostic laparoscopy of the small bowel - CORRECT ANSWERS ✔✔Because the small bowel spans the entire abdomen both LUQ and RLQ so surgeon and assistant need to stand on both sides of the table (as opposed to some surgeries like appy where both surgeons stand on patient's left and operate on patient's right). In reference to the location next to the patient, what are the best positions for the monitors in laparoscopy? - CORRECT ANSWERS ✔✔Best monitor positions are by patient's left shoulder and right hip.
- CORRECT ANSWERS ✔✔Ports all on left side of abdomen in a line How do you "run the bowel" laparoscopically? - CORRECT ANSWERS ✔✔- Systematically
- Start at cecum and work proximally, keep track of where you are to ensure complete examination.
- Usually requires changing camera angle several times. Tips to avoiding enterotomy when "running the bowel" in laparoscopy? - CORRECT ANSWERS ✔✔- Use instruments with non-traumatic tips
- Handle mesenteric fat rather than bowel wall itself
- Keep instruments in view at all times. Where should you start "running the bowel" if you have a small bowel obstruction? - CORRECT ANSWERS ✔✔- Start at ileocecal valve with collapsed bowel.
- Initial entry under visualization
- Exam distally (at the decompressed bowel)
- Manipulate any dilated bowel with EXTREME caution
Has diagnostic laparoscopy with a traumatic diaphragmatic injury caused tension pneumothorax? - CORRECT ANSWERS ✔✔No. And diaphragmatic and GI injury are often undetected with traditional imaging but able to be identified with laparoscopy When should you NOT peform a diagnostic lap in a trauma patient? - CORRECT ANSWERS ✔✔When they are hemodynamically unstable List methods of laparoscopic biopsy - CORRECT ANSWERS ✔✔- peritoneal washings/scrapings
- Fine needle aspiration (FNA)
- Core needle biopsy
- Incisional (wedge) biopsy - remove only a portion of it
- Excisional biopsy - remove the entire lesion (usually for smaller lesions) Why should avoid cautery when taking a biopsy? - CORRECT ANSWERS ✔✔Cautery can sterilize it, distort architecture, or destroy cells. You can use cautery after the specimen is taken out. If the target tissue is visible with the camera in the abdomen, how many additional ports should be placed to
obtain a biopsy? - CORRECT ANSWERS ✔✔None! Use the camera port for your camera and then watch as you place the percutaneous needle into the specimen. What sort of needle should you use for a FNA in laparoscopy? - CORRECT ANSWERS ✔✔A spinal needle that can reach target tissue through abdominal wall. What do you need to do with the plunger of your needle for a FNA biopsy before you remove the need from the abdominal cavity? - CORRECT ANSWERS ✔✔Release the plunger to release the suction before you remove it from the abdominal cavity. Then detach the needle from the syringe and fill up the syringe with air to push out contents of needle into specimen cup. For what organ would you most commonly perform a core needle biopsy? What guage of needle is it? - CORRECT ANSWERS ✔✔Liver biopsy
- cirrhosis or carcinoma
- Should not do it for a hemangioma (high amount of bleeding) Uses a 14 or 18 guage needle What are laparoscopic biopsy forceps? - CORRECT ANSWERS ✔✔Specifically designed laparoscopic
What type of biopsy is a lymph node biopsy? What is a key principal to all lymph node biopsies? What can you use besides cautery to help get control of vascular supply of a lymph node? - CORRECT ANSWERS ✔✔- Excisional biopsy
- Handle gently, prevent excessive damage or bleeding
- endoloop on nodal lymphvascular supply can be used to avoid damage caused by cautery If you determine malignancy in ovarian biopsy what should you do for a full staging procedure? - CORRECT ANSWERS ✔✔Peritoneal washings, diaphragm sampling, paracolic gutter sampling bilaterally, para-aortic lymph node sampling How do you prevent seeding of the abdomen with an ovarian specimen or causing ovarian remnant syndrome?
- CORRECT ANSWERS ✔✔Use a retrieval sac or ensure small specimens are small enough to fit through the port you have in place. After you biopsy a hollow viscous such as bowel, how do you repair it? - CORRECT ANSWERS ✔✔Serosal suture to avoid leakage post-operatively.
Around what types of structures should you avoid monopolar cautery? - CORRECT ANSWERS ✔✔monopolar cautery should be avoided around vascular structures, ureters or nerves. What types of biopsy are commonly used with ultrasound guidance? - CORRECT ANSWERS ✔✔Core needle biopsy or FNA What are the benefits to using a braided suture over a monofilament suture for laparoscopy? - CORRECT ANSWERS ✔✔braided sutures easier to handle, less tendency to fray, less throws per knot, less memory in the suture Why would you choose a suture that is dyed rather than an undyed suture for laparoscopy? - CORRECT ANSWERS ✔✔A suture without dye may absorb blood and blend into background making it difficult to use which needle type is safer to use in laparoscopy, tapered or cutting? - CORRECT ANSWERS ✔✔Tapered needles Name two locations for the locking mechanisms for needle drivers in laparoscopy - CORRECT ANSWERS ✔✔- pistol grip
What are the ways you can position the needle correctly in your needle driver? - CORRECT ANSWERS ✔✔- Pick up needle in correct orientation (rest needle on tissue)
- Pass back and forth between instruments
- Nudging needle and manipulating suture What is a trick to know that your needle is perpendicular to the needle driver? - CORRECT ANSWERS ✔✔A glint of light off of the needle indicates that the needle is perpendicular to the driver. How do you avoid tissue damage when passing a needle through tissue? - CORRECT ANSWERS ✔✔Pull the needle through the tissue at the exit site along its arc (curve your wrist to follow the curve of the needle as you pull it through) When would you use a sliding square knot? - CORRECT ANSWERS ✔✔When approximating tissue under some tension How do you reduce friction when pulling the suture through tissue in preparation for throwing an extracorporeal knot? - CORRECT ANSWERS ✔✔Use an assisting instrument as a fulcrum. After you place needle through tissue and are preparing to pull the needle back
through your port, place the instrument in your non- dominant hand near the tissue and braced against the suture as you pull so that you do not inadvertently pull the suture out of the tissue When using an open knot pusher, when do you throw the knot -- before or after placing the knot pusher on the suture? - CORRECT ANSWERS ✔✔Before. Throw the knot, then place the open knot pusher on the suture to push the knot down
- CORRECT ANSWERS ✔✔Place one strand through the knot pusher, then throw the knot. Use a clamp on the other end of the suture to prevent it from inadvertently getting pulled back into the abdomen. When throwing an extracorporeal knot, do you push down in front or behind your other suture strand - CORRECT ANSWERS ✔✔Push the suture in front of the throw to prevent damage to the suture like fraying. What is a Roeder's knot? - CORRECT ANSWERS ✔✔It is a knot that is tied completely extra-corporeally and then pushed down to secure a suture that is approximating tissue. This is different than an extracorporeal knot that is not tied until you push it down with a knot pusher.
What is the ideal suture length for intracorporeal knot tying? (hint, same length as what you are given for the FLS task!) - CORRECT ANSWERS ✔✔15 cm (6 inches) What is the ideal suture length for extracorporeal knot tying? - CORRECT ANSWERS ✔✔75 cm (30 inches) What is the ideal orientation for suture (what positions on the face of a clock) - CORRECT ANSWERS ✔✔3 o'clock to 9 o'clock What steps should you take to control bleeding intraoperatively? - CORRECT ANSWERS ✔✔Optimize visualization, grasp and hold the bleeding source, maintain exposure to it, and apply hemostatic techniques When the trocars are placed through what muscle you have the highest risk of injury to the epigastric vessels - CORRECT ANSWERS ✔✔rectus muscles Name several ways to control bleeding from a port site - CORRECT ANSWERS ✔✔- Energy source, direct pressure, suture ligation,
- Pass foley catheter through port site and inflate balloon to tamponade the site If conservative measures fail to control bleeding at a port site, what type of suture can you place? - CORRECT ANSWERS ✔✔Full thickness abdominal wall suture placed cephalad and cauded to port site through skin incision. Through abdominal wall and into abdominal cavity with either a Keith needle or spinal needle. Causes of retroperitoneal bleeding - CORRECT ANSWERS ✔✔Verees needle or trocar injury What must you suspect if you have free blood that is clearly not from a port or operative site? - CORRECT ANSWERS ✔✔a retroperitoneal bleed If you identify that you have a retroperitoneal injury what should you also be concerned about? - CORRECT ANSWERS ✔✔An occult bowel injury (i.e. you may have passed the verees through bowel and then entered the retroperitoneal space) What do you do if you identify a trocar injury with retroperitoneal hemorrhage - CORRECT ANSWERS ✔✔Urgent open ex lap
