00:00Hello friends, this is a case of laparoscopic management of ruptured ectopic pregnancy.
00:08This patient has right side tubal pregnancy and we are in emergency performing laparoscopic
00:15surgery.
00:16So, here various needles introduce supramolical and we will perform irrigation suction and
00:22hanging drop test.
00:25So, ectopic pregnancy is a surgical emergency, you should immediately perform surgery and
00:32we can see fortunately blood is not coming in the aspiration and we are doing here piston
00:39test that is plunger test.
00:42Instead of hanging drop test you can do plunger test and we can see here this column of the
00:48saline is sucking in because inside the abdominal is an intra-abdominal negative pressure.
00:54So that will suck the saline in and that is one of the very means a strong conformation
01:00that your varice needle is inside the abdomen.
01:03And after we have started insuffilating the patient.
01:07Unfortunately right tube is just about to rupture and the patient has tachycardia and hypovolumia
01:17and we are planning immediate surgery.
01:21So let us see how it is going on.
01:23We are keeping the preset pressure 15 and slowly actual pressure is increasing.
01:30And as we can see in this video that abdomen is distending.
01:35Homogenous distension is there.
01:37That is one of the factors that your gas is going in abdomen.
01:42Now actual pressure is reached to preset pressure.
01:45And now we will extend the incision to put the first trocar.
01:52That is the optical port.
01:59The trocar, the port has to be held like a pistol.
02:03Head of the trocar, we rest over thin aramines, middle finger should wrap around the ear inlet
02:09and the index finger should be pointed towards the sharp end.
02:14And now with a screwing movement, we will introduce our trocar safely inside the abdomen.
02:20And once you will get a giving way sensation, then you will get hissing sound.
02:26Head of the trocar will get a hissing sound.
02:28This is hissing sound because tip of the trocar has a hole which will leak from the back.
02:33And that is also one of the conformation that you are inside the abdomen.
02:39After that telescope is introduced.
02:41And then we will put table down and head down.
02:46Patient will go to the Trendelenburg position.
02:49So the head will be 30 degree down.
02:52And slowly head is going down.
02:55And then right side, this is the tube.
02:58And we will make a baseball diamond concept.
03:00Index finger will be put just above the tube, where you can feel the transient illumination
03:05by the telescope.
03:07And we will make a shape of a diamond, baseball diamond, thumb is over them like us.
03:11The second port will be 7.5 cm lateral and below.
03:16Telescope is 24 cm from the target.
03:19And the instruments are 18 cm from the target because your length of the instrument is 36 cm.
03:26So we will perform two epsilateral port here.
03:29Now head of the patient is 30 degree down.
03:32And this is the second port which will have your right hand.
03:37Now third port will be again 7.5 cm and lateral to the second port.
03:43And that port will be your left hand to take an atraumatic rasper.
03:47So now we are introducing the third port.
03:50And that will be again 7.5 cm lateral and below the second port.
03:55And it is approximately 2 cm above and medial to the anterior superior iliac spine.
04:02So all the three ports have been introduced.
04:04And now we will start the surgery.
04:06The OT light is switched off.
04:08That's why it's dark.
04:09And now we are seeing inside.
04:11That we can see in the anterior cul-de-sac blood is collected.
04:15And omentum is also trying to adhere and trying to arrest this.
04:20It has just ruptured.
04:21So we can see the clot is still there.
04:23And this is ambulary pregnancy.
04:25There is one paravarian cyst also.
04:28That cyst also later we will rupture.
04:30And you can see clot is trying to cover and this is early ruptured ectopic.
04:37And this is cul-de-sac is also filled with the blood, anterior as well as posterior cul-de-sac.
04:43So omentum is also started trying to arrest this and ovary.
04:48But right now this is free, it is not adhered.
04:52So first step is that we should use suction.
04:55And we should suck all the blood which is coming out of the rupture site.
05:02And suction will suck so that your vision will improve.
05:05Because we know that red color of the blood has this bad property of absorbing most of the light.
05:12So suction is important.
05:13All the clot and the blood collected in anterior cul-de-sac, posterior cul-de-sac is sucked.
05:19So this suction is performed.
05:30And after that we will hold the tube.
05:35And sometime to break the clot you may have to shake the suction.
05:40So that clot will liquefy and then with the 5 mm suction you can suck it.
05:46Sometime maybe 10 mm suction is required.
05:49Now here atraumatic rasper is separating this and you will give the anteromedial traction
05:55over the tube.
05:58So we have a ligasure in the right hand and atraumatic rasper in the left hand.
06:04Now this omentum is separated and we should try to remain as nearer as possible to the tube.
06:11This is IO ligament that is infundible ovarian ligament and you should not go near the ovary.
06:18Because this is IP ligament, this is IP ligament and this is IO ligament.
06:23Here we can see ureter.
06:25Once you will push the rectum towards the right and you will go to the just below the IP ligament
06:31we can see peristalsis of ureter is visible.
06:35And that's why anteromedial traction is important so that you will be away from ureter and you
06:40will be away from iliac vessel.
06:43After that this is ligasure, avoid going nearer to the IP ligament, remain near the tube so
06:49that collateral injury will not happen and devascularization of ovary will not happen.
06:55And then slowly we can keep on cutting eye oligament followed by mezosalpins.
07:03The salpingectomy is a very easy procedure you can do by ligasure or harmonic or even by
07:09simple bipolar you can do hardly take five minute time and you can cut the tube.
07:16So we are over the mezosalpins now and we are reaching near the uterus.
07:22And when you are going uterus, you should be six millimeter away from the uterus.
07:28Very nearer to uterus, you should not coagulate and you should not cut otherwise ascending uterine
07:33branch will be also coagulated and then ovary supply of ascending uterine will be compromised.
07:40And if you are to go very near to the uterus, there is a chance of utero peritoneal fistula.
07:45So after six millimeter you should coagulate.
07:48So that entire tube is coagulated.
07:50And now this is just the final part of the mezosalpins which is getting coagulated and cut.
07:57So we can see so quickly you can do salpingectomy.
08:04And it is over.
08:06After that we will check the cul-de-sac everything is fine.
08:11Some flimsy adhesions are developing with the left tube that you can separate.
08:16In the ovary already this cyst is punctured.
08:20But still you should try to remove this follicular cystic tissue and you may drill it because sometime
08:28drilling is necessary because there may be some time chances that it can develop into
08:34the cyst.
08:35Although this is not a true cyst, this is just a follicular.
08:40So this is the harmonic.
08:42You will go with the harmonic and just within few millimeter puncture you will do and that
08:48fluid will come out.
08:50So this is almost over and you can perform the surgery and this is done.
08:56Now once it is over after that next step is you should try to clean the cul-de-sac anterior
09:01posterior cul-de-sac and paracolic gutter should be nicely cleaned and repeated suction irrigation
09:08should be done.
09:09So that lavage will be there care should be taken that that blood should not gravitate to
09:15the upper abdomen.
09:16If it is gravitating to the upper abdomen then you may need to do little suction over
09:21the Morrison's pouch also.
09:24So this is over after that we will take a trocar with the stone holding forcep and our assistant
09:30will push into the posterior fornix.
09:34That trocar should have the 10 mm port and it should have inside a stone holding forcep so
09:41that we can give culpotomy incision and then we will use a endobag through the culpotomy
09:47and we can remove this through the culpotomy wound.
09:51So just this is a trocar with the stone holding forcep and you have to give just 10 mm a small
09:57incision 3 cm below the arc of utero-sacral ligament.
10:02This incision should be given and now this stone holding forcep is blunt instrument which will
10:09automatically protrude through the posterior cul-de-sac and then after this incision it
10:15can be inserted inside.
10:17So we can see now this is the stone holding forcep which is just cutting and it is entering
10:24into the abdomen during that introduction be careful that sharp instrument should not
10:29be used and here is the cannula.
10:32So cannula also that is the port is inside this is 10 mm port in the cul-de-sac and through
10:39this 10 mm port you will introduce one endocatch that is a commercially available endobag is coming
10:46through this 10 mm port and it is self retaining so it will open.
10:51Once you will push like a piston it will open and once it is open then you can put this ectopic
10:59into the endobag.
11:03So this is our ectopic and we will introduce into the endobag and then it will close it
11:08as a metal ring also that metal ring will be self retaining you don't have to struggle to
11:14open the endobag and once you will pull then metal ring will come out and then purse string
11:19will close the mouth of the endobag like a purse string and then slowly you will pull it and it
11:26will easily go through the vagina because posterior fornix is a stretchable so easily it will enter
11:31into the and it will come out and that's all surgery is over after that we will do little more
11:38lavage so that we will clean the pelvis nicely and patient head at that time should be up so that
11:45all the blood collected in the paracoli gutter will go to the pelvis you can shake the bowel you can shake
11:51the momentum you can shake the small bowel so that all the blood collected will go to the pelvis and then
11:58you can do final suction from entry and posterior cul-de-sac so thank you very much for watching
12:04this video this was just a simple case of initial rupture ectopic pregnancy which was timely managed
12:12thank you very much have a nice day
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