00:00hello friends this is a case of right-sided salpingo-offrectomy with
00:06appendicectomy this patient has a large 18 centimeter ovarian cyst patient age
00:11is 64 so we are not planning to do ovarian cystectomy we will perform
00:16offrectomy and because the patient has recurrent pain previous episodes of
00:21appendicitis so we will do appendicectomy as well and we will remove it by
00:26colpartomy so please come see the case here the ovarian cyst is up to umbilicus so
00:32we will do the access to the palmer's point as you know the palmer's point is
00:36mid clavicular line just below the costal margin so this is the costal margin it is
00:41the left and this is the right subcostal and now this is the mid clavicular line
00:47this is a mid clavicular line but we do here one modification this is palmer's
00:52actually original palmer's is here but we give two centimeter above so that you
00:57don't need to close this port so what we will do that we will first give one a
01:02small stab wound two millimeter stab wound over the inferior criss of umbilicus
01:08sorry over the this two centimeter above the palmer's and after that you will take
01:15the varice drill and point the varice drill and stretch the abdominal wall down and
01:20point to the varice drill right towards the stomach and then you can take
01:25irrigation test suction test and hanging drop test so this is the syringe with
01:32the saline and here is the irrigation test going freely suction test nothing come
01:39out and hanging drop test after that you can attach the tubing of the
01:46insufflator and hanging drop is sucked in this is the tubing of the insufflator we
01:53are using a striker laproflator with the co2 warmer in inbuilt and then you will
01:58start the insufflation so we are keeping here pre-check pressure 15 and actual
02:04pressure is slowly as you can see this is the digital output of our insufflator
02:09actual pressure is slowly increasing and once it will reach to the 15 then we will
02:16stop the insufflator take the varice drill out enlarge the incision to 11 mm and
02:26then the trocar will be introduced and then telescope will be introduced inside so
02:32this way you can enter inside and after that we will start seeing the diagnostic now
02:39this is the baseball index finger is on the right infant lopelvic ligament and thumb is
02:45on the umbilicus and this is the shape of a diamond which you have to make and now it
02:51is more towards the right infant lopelvic so you will draw the arc and table is
02:57coming down percent head is 30 degree down this is first arc at 18 cm and this is
03:03second arc at 24 cm so telescope already we will continue with the palmer's point
03:09but primary port 7.5 cm lateral this will be your left hand and this will be your right
03:15hand so that a good triangulation will be maintained and 60 degree manipulation angle will be achieved
03:21after that this is the second port that is the working port 5 mm which will introduce 7.5 cm
03:30lateral and below the umbilicus this is only 5 mm you don't need 10 mm in this side because we are
03:38planning to remove the ovary as well as appendix through the colpo tummy wound so that you don't
03:43need to enlarge the incision and you don't need big big incision also so this is 5 mm and this is the
03:59trocar assistant gynecologist is introducing here and this is the another port after that you can
04:13puncture the cyst by aspiration needle so here is a aspiration needle and you can initial few ml of
04:21the cystic fluid you can collect into the syringe so that you can send it for FNAC so this is the
04:29trocar inside and this is the another trocar other side and now here is the aspiration needle will
04:39come and it will puncture it is punctured and now in the syringe you will collect the fluid for the
04:48cytological examination here this is the fluid and then suction will suck the all the fluid out and it
04:54is very good simple easy case because all the cystic content is serious it is no any any mucinous or
05:04no any dermoid or no any chocolate it is simple cyst but still the present is postmenopausal so we
05:12will perform the ophrectomy there is no point doing the ovarian cystectomy in those cases so here
05:19antero medial traction will be given and with the harmonic directly you can do salpingo frictomy
05:26keeping yourself as nearer as possible to the ovary and antero medial traction will be given here we
05:33are using harmonic a scalpel but it is up to you you can use like assured you can use bipolar you even
05:41can use monopolar either there is no issue because in front of pelvic ligament is a easy easy process to
05:48allow the desiccation and dissection simultaneously so this is now major salpings and then you will go
05:58to the medial end near the fallopian tube so this is a salpingo frictomy of the right side which is
06:06being carried out now couple of time you can apply little minimum like little coagulation near the
06:25uterus so that there will be no any uteropatorial fistula and then you can coagulate six millimeter
06:31of the tube nearer to the uterus and after that you can cut it so here it is done and now we will
06:51start doing the this sponge pushing in the posterior fornix this is the assistant pushing the sponge in
06:58the posterior fornix and then there will bulge of the sponge and by the harmonic approximately two
07:03to three centimeter below the arc of uterus sacral ligament harmonic is cutting the posterior fornix
07:09that is posterior colpotomy colpotomy wound is very good for tissue retrieval and if you give only two
07:16to three centimeter incision then this sponge will come inside the abdomen over the bulge of the this
07:24sponge there is no possibility of any this bubble or rectum to come out because once you will hold the
07:31cervix with the tenaculum then easily this sponge can be by a screwing movement you will bring the
07:37sponge in now assistant is screwing the sponge and it will come inside the abdomen little bit vaginal
07:46epithelium has to be cut little more and now it is done and now by a screwing movement it is coming
07:52inside uterus sacral ligament will not be touched so that there should not be any effect on the this
08:01support of the uterus so now with this a screwing movement it is coming in and now you can take it
08:10out and here it is going out after that by the side of this a sponge you can put a claw forcep there is a
08:22claw forcep coming that is also called as gall bedded extractor but here as a gynecologist we say
08:29crocodile forcep or claw forcep now the cysts can be held and then slowly entire ovary tube and cysts
08:36can be pulled through the colpotomy wound and here it is going out your assistant here with the claw forcep
08:47we can see this is vaginally coming out and even the huge cysts sometime we have performed a cyst of
08:5430 centimeter also we have performed and that also can be taken out easily we can see here that much
09:02huge cysts all even bigger than that can be taken out by the colpotomy nicely and now you can do thorough
09:09lavage because it is a dependent area so there is no chance of any fluid to retain there now we will
09:15continue appendicectomy here is the momentum and now the appendix will be held up with the same port you
09:22can do appendicectomy also we don't need any extra port and after that you can retract the appendix up
09:29and with the harmonic you can keep on separating the major appendix
09:50slowly major appendix here teflon jaw of the harmonic should be kept towards the shechem
09:55so that any current will not any vibration will not pass over the appendix
10:01and there will be no thermal injury
10:13so now entire major appendix is free it is reached up to the tinea coli up to the cecum
10:27now you can get one visras knot that is extra corporeal knot then you put the grasper in the loop
10:35catch the appendix and negotiate it to go behind the structure now bring to the base of the appendix and you
10:42can tie a knot the tighter knot will be tightened
10:50and it is done
10:54after that you can cut the suture
11:02and then with the harmonic you can sacrifice it leaving six millimeter away from the knot
11:12and it is over appendicular side will seal so there is no issue now again this is a stone holding
11:25forcep you will push the stone holding forcep from the posterior fornix and the base of the appendix will
11:32be held in the spoon forceps so that no spillage and it will be taken out after that you can take a bite
11:39vaginally to close the pop this vault and you can close it so you can see vaginally here it is closer
11:46so thank you very much for watching this video this was just a simple case of
11:52right side salpingo effectomy together with the appendicectomy thank you very much have a nice day
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