THE TWO-PORTAL LAPAROSCOPIC OVARIECTOMY TECHNIQUE
Before performing a laparoscopic ovariectomy, inform the owner about the procedure, and obtain a signed permission-to-treat
form (including permission to convert to an open procedure, should it be necessary) and a signed estimate form that specifically
states laparoscopic ovariectomy. Also, make sure all equipment is sterilized, and prepare the patient, including evacuating the bladder (see the related sidebar titled "General laparoscopic ovariectomy setup instructions for technicians"). I also instruct my technician to administer 20 mg/kg cefazolin intravenously during induction. If any perceived breaks
in sterility occur during the procedure, I continue appropriate antibiotic therapy.
Step 1: Position the patient
Position the widely clipped animal in dorsal recumbency on an endoscopic patient positioner that has been securely attached
to the surgery table. Secure the patient with the positioner's straps and buckles, making sure the upper thigh straps are
secure since they will help hold the patient's legs open when the patient is rotated into the lateral position. Do not use
the surgery table ties to secure the patient's legs. Adjust the front of the positioner so the open area between the front
sliding V and the fixed caudal V is wide enough to allow easy access to the portal areas and the ovarian tacking sites lateral
to the third and fourth mammary glands. Tape may be needed to secure smaller patients instead of the straps. Make sure enough
space is available to move easily around the caudal end of the surgery table to the other side. Temporarily place the instrument
stand to the side of the tail end of the surgery table. Aseptically prepare the surgical field in the standard fashion.
Step 2: Drape the area
Have a nonsterile assistant open the sterile box pack cover and place it toward the backsplash of available counter space.
After donning a cap, a mask, a gown, and gloves, the surgeon removes the large paper drape from the top of the box and places
it to the side on the sterile cover drape. The four towels and six towel clamps are used to drape the wide abdominal area.
Place the cranial and caudal towels first, and then clamp in the first side towel to the cranial towel. Next, clamp it again
farther dorsally following the rib cage to just short of the prepped edge (near the last rib), and place the final towel clamp,
securing it to the caudal towel. Do the same on the opposite side.
Step 3: Arrange the instruments
Figure 3
|
Arrange the instruments for chronological use on the surgery counter (Figure 3) from left to right: the Veress needle, insufflation hose, No. 11 or No. 15 blade (not pictured), suture pack, 5-mm Storz EndoTIP cannula, and another 5- to 14-mm cannula-trocar assembly (depending on the patient's size).
Remove the trocar from the cannula-trocar assembly and place it and the cannula side-by-side. Place the camera head and light
cable next and the endoscopic grasper toward the back next to the laparoscope.
Step 4: Further positioning and site preparation
Have an assistant move the instrument tray to the tail end of the surgery table and place the tower at the head of the table.
I generally do not tilt the surgery table head down (Trendelenburg position8 ) unless I have difficulty locating the ovaries. Place the large paper drape over the toweled-in area, and cover the area
from the patient's head to the instrument tray stand.
Have the assistant open the outer wrap on the general surgery pack and place the pack on the drape-covered instrument stand
(the pack's weight helps keep the drape in place when the patient is moved from side to side). Next, cut the drape over the
two portal entry areas (see below for the exact location of the portals) and secure the drape with four towel clamps.
Figure 4
|
Run the insufflation, light cable, and camera head lines through the cranial and caudal towel clamps (use the eyes and lock
boxes) to help keep the lines in the sterile field (Figure 4). Hand the assistant the filter end of the insufflation line to be plugged into the insufflation unit.
|
Featuring Information from:
