Contraindications (things that really need open procedures being done)

1. General
   • Coagulopathy
   • Shock
2. Specific
   • Peritonitis
   • Obstruction

Essential components

1. Establish pneumoperitoneum
2. Insertion of trocar
3. Inpection of cavity
4. Removal of trocar and closure of wounds

Pneumoperitoneum

1. Trendelenburg position (head down) - position bowel away from pelvis
2. 1-2cm infraumbilical incision (transverse or vertical), deepen down to rectus sheath
   • Closed laparoscopy - Veress needle
     1. Hold up abdominal wall, insert Veress needle perpendicular to skin until "give", then point needle towards pelvis at 45'
     2. Confirm satisfactory insertion - saline drop test or aspiration
   • Open laparoscopy - Hassan cannula
     1. Pick up / incise rectus sheath. Place sutures on each side of linea alba
     2. Incise peritoneum and enter peritoneal cavity under direct vision
     3. Insert finger, sweep away adhesions
     4. Insert port + stay sutures
3. CO₂ insufflation (aim pressure 0-5mmHg)
4. Percuss abdomen to ensure symmetrical abdominal distension
5. Maintain pressures of 13-15mmHg, volume of gas 4-5L

Insertion of trochar

1. Introduce cannula using corkscrew technique (aim towards pelvis) - check position by releasing gas tap/vavle (hearing air)
2. Attach camera
3. (Bleeding can be controlled by inserting a foley catheter to achieve compression)

Insert other ports under direct vision

Position of ports

1. Infra-umbilical pneumoperitoneum (veress/hassan)

2. Epigastric trochar / camera

3. Epigastric cannula

Finishing

1. Remove under direct vision
2. Check port site for haemostasis
3. Umbilical/epigastric ports should be closed formally
4. Skin closure by tapes/sutures
5. + wound infiltration with bupivacaine for analgesia

Common complications

1. Rectus sheath insufflation, gives high pressures - stop
2. Misting of equipment (if not adequately pre-warmed)
3. Blood on lens can be wiped on omentum