Proper positioning of the patient in the lithotomy position prevents patients’ injury and facilitates easy conduct of surgery. The hip should be flexed at 45° keeping the thighs parallel to the abdomen. Allen stirrups allow good support to the lower limbs and facilitate their movement with great ease. Following examination under anaesthesia and emptying the bladder a uterine manipulator should be inserted into the cavity to facilitate moving the uterus in different directions. This is necessary in most major laparoscopic procedures. We use a Zumi manipulator for that purpose.

The Vere's needle and the umbilical trocar should be inserted at 45^o while the patient is flat on her back on the operating table. The needle lock should be kept open during its insertion to allow suction of air into the cavity by the negative intraperitoneal pressure. This would allow the bowel and omentum to float away from the tip of the needle as it is introduced. It is NOT meant to allow gush of blood out of the abdomen if a vessel is punctured as frequently quoted. Proper positioning is checked by injecting 10 ml of saline into the abdominal cavity with no resistance. No fluid, blood or stools could be aspirated back when the needle is properly sited.

Intraperitoneal pressure should be less than 2 mm at the beginning before switching to maximum flow. Pressure should then be kept at or under 15 mm during the whole procedure except when the umbilical trocar is introduced when a pressure of 20 mm should be used. This would allow adequate separation and distance between the anterior and posterior abdominal walls for safety of the aorta and vena cava.

The patient is then put in a head-down position rolling the small intestine out of the pelvis. A 30^o head-down position would be needed during major procedures involving the pouch of Douglas.  Injury to the inferior epigastric arteries could be sustained while introducing the lateral lower trocars as these vessels could not be trans-illuminated. Accordingly these trocars should be inserted under direct vision lateral to the peritoneal folds made by these vessels. Similarly to avoid injury to midline structures the suprapubic trocar should be inserted under direct vision as well. The bladder should be empty and the uterus retroverted using the Zumi manipulator.

Occasionally alternative sites should be used to avoid suspected areas of adhesions. This is important in women who had previous surgery with subumbilical incisions. A small scope could be inserted beneath the costal margin in the midclavicular line on the left side of the abdomen (Palmer's point). This would allow adequate mapping of any adhesions and help with insertion of other trocars and a larger scope under direct vision.

To facilitate safe surgical procedures

• Pre-operative bowel preparation could help with good exposure during surgery by having empty bowel loops and allows repair of certain bowel injuries laparoscopically at the same time.
• Meticulous application of safety procedures during insertion of the needle and trocars as one third of all injuries occur during this initial stage.
• Theatre table should allow tilting the patient in all 4 directions as necessary during surgery
• The surgeon should always concentrate on the monitor. The area of interest with the best focusing and magnification should be kept at the centre of the monitor to reduce 2D effect.
• The size of the monitor dictates how far it should be away from the surgeon. The monitor should be ideally placed away at a distance 5 times the diagonal diameter of the monitor. This indicates that smaller monitors need to be placed further than smaller ones.
• The assistant should be in charge of introducing, removing and changing the different instruments through the operative trocars.
• For ideal and easy  tissue manipulation equal parts of the operative instruments should be kept inside and outside the abdominal cavity. Also maintain constant tissue, instrument and eye sight ratio.
• Good exposure of the operative area should be maintained during the whole definitive surgery.  All trocars should be used for operative manoeuvring and not for tissue retraction. A trocar used for retraction is lost for surgery as previously quoted. Transparietal fixation of intrusive large bowel and ovaries to the anterior abdominal wall could be done if necessary.
• In patients with extensive adhesions due to endometriosis or previous surgery the ureters might be at risk of injury or kinking. In such situations 5 french ureteric stents could be inserted through a 30⁰ cystoscope to identify and protect the ureters. This should be used sparingly and only when necessary as it could lead to ureteric injury, haematuria or even spasm causing postoperative anurea.
• Trocars should be placed at higher level when dealing with a large  uterus or ovarian mass.
• Bipolar energy should be the preferred option. Alternatively using cutting monopolar energy for both cutting and cauterisation is a safer option as it has lower voltage and a lesser risk of arcing.

Further important points about technique

• I deally CO2 outflow from the insuflator should be fitered before passing it into the abdominal cavity to reduce bacterial contamination.
• Cold temperature light does not mean it is not physically hot to touch. Cold light here refers to colour temperature and not physical heat. To have bright white light the colour temperature should be high in the region of 5000^o Kelvins or more. This would deteriorate with the age and physical damage of the source and conductors.
• Broken light fibres within a light cable would interfer with the quality of the transmission. Accordingly they should not be twisted, folded or dropped.
• A 3-chip camera is better than one chip alternatives as one chip would be used for each of the 3 main colours [red, green and blue] rather than one chip being used for all 3 colours at the same time with cheaper cameras.
• A laparscope of good quality should have long depth of vision to provide sharp and stable images all over the field without the need to push it in or out.
• Black shadows arround the image are not due to a bad light cord as usually suspected. Changing the light lead would not solve the problem. It always follows loss of alignment of the optics within the scope. In this case the light path would be deflected in different directions before reaching its distination. This is a process called vignetting and it indicates a damaged laparoscope most likely due to repeated sterilisation. Heat would change the glue used to fix and align the lenses (optics) within the scope. Accordingly each laparoscope would have a fixed life span as to how many times it has been sterilised; usually 500 times before deteriorating.

Futher important points about safely

• Incidence of complications after laparoscopic surgery depends on the complexity of the procedure and the experience of the surgeon. It is reported as 0.6 - 1.6 per thousand cases. It also depends on the size of the patient and whether she had any pelvic surgery in the past.
• Only one third of bowel injuries are discovered intra-operatively. Electrosurgically sustained bowel injuries might show 3 - 5 days later.
• Open laparoscopy might reduce the risk of vascular but not bowel injuries.
• After adhesiolysis involving bowel loops or excision of rectovaginal deep endometriosis bowel integrity should be tested under water for any leakage.
• Bowel injury could be repaired during surgery under the same anaesthetics in the following situations
  • the bowel has been prepared preoperatively
  • there is only a single clean injury not sustained electrosurgically
  • there is no leakage of bowel contents into the peritoneal cavity
  • there is satisfactory exposure to reach the injured area
  • the suture allows good approximation of the edges without tension
  • and most important is the experience of the surgeon involved
• Patients should be given postoperative discharge information regarding symptoms of complications and how to contact the hospital without delay in case of doubt.

For more information see abdominal exploration