Technical Caveatstips

■ Trocar and hand incisions noted in the operative technique section are for right-handed surgeons. Use mirror image placement for left-handed surgeons.

■ The nondominant hand should be in the operative field and the dominant hand performs fine dissection using laparoscopic instruments.

■ Hand incisions are positioned to allow the back of the hand to be used as a retractor while using the fingers to grasp and dissect.

■ If you are using your hand just as a retractor, your incision was not properly placed or you are not using your hand correctly.

■ If you are using your hand as a retractor and not for dissection, think about locations where you can insert a 5 mm trocar for a laparoscopic retractor, freeing up your hand to be used as an instrument.

■ Experienced laparoscopists initially may not use their hand properly. Do not use your hand as a passive instrument and perform standard laparoscopic surgery. You will be surprised how fast you can progress with your hand compared to standard laparoscopy.

■ The surgeon with the hand in the operative field should be using the dissecting instruments. The surgeon has the proprioception, depth perception, and control of the tissues and should control the instruments.

■ Insert a rolled-up lap pad into the abdominal cavity with your hand. It can help retract and dry tissues. Drier tissues are easier to grasp and dissect, and tissue planes are easier to identify. It also saves time not having to stop and insert a suction/irrigating instrument.

■ Uses of your hand include: determining optimum position of trocars and insertion of trocars; locating laparoscopic instruments as they are inserted into the abdominal cavity; palpation; depth perception; proprioception; counter traction; and vascular control.

■ Exposure! Do not work in a hole. Obtain wide exposure. Work in layers. If you get into bleeding while working in a hole, it is hard to get control of the bleeding vessel. If you have good exposure you will more likely be able to get control of the bleeder.

■ Do not use monopolar cautery near veins, especially large veins such as the renal vein or vena cava. The large volume of fluid in these vessels acts as a great conductor and may be the path of least resistance for the current to get back to the ground plate, resulting in a hole in the vein wall.

■ The harmonic scalpel is much safer for dividing small vessels compared to monopolar electrocautery instruments, but takes longer to divide the tissues. If ever uncertain, be safe and patient; use the harmonic scalpel.

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