Laparoscopic Ovariectomy Step-by-step

Pre-Operative Preparation
  1. Two-port technique clip

    Clip from xiphisternum to the pubis including areas normally clipped for a bitch spay.

    The area where the hook will be placed must also be clipped. For this you will need to extend the clip along the flanks of the patient. Clip at an angle from the xiphisternum to the sublumbar muscles.

  2. Surgical Scrub

    Aseptically prepare the clipped area.
    You can also concentrate a second scrub on the sites of the surgical ports:

    – The cranial port is placed halfway between the xiphisternum and the umbilicus.
    – The caudal port is placed 1cm caudal to the umbilicus.

  3. Positioning

    Place the patient on a tilting table (left – right tilting) or a tilting patient positioner that has been fully secured to the surgical table.

    Secure a strap over the chest of the patient, just cranial to the xiphisternum.

    Also secure the caudal part of the patient in place using table ties onto the hind limbs.

    Test the positioning by tilting the table prior to draping.

Opening the Surgical Packs in Order
  1. Equipment Introduction

    Please review the Equipment Introduction

  2. Open the packs as follows

    – Table drape – Large plastic green drape / large patient drape

    – Surgical kit, including towel clamps

    – No. 11 scalpel blade

    – 2.5ml syringe and ¾ inch 24g needle

    – Local anaesthetic (bupivacaine) – hold upside down if using pre-opened bottle

    – Laparoscopy instruments: Babcocks, metzenbaum scissors, cautery (handles, sheaths, inserts of each). Also, hook if using.

    – Laparoscopy cables and tubes: cautery cable, insufflation tube.

    – Pick up cold sterilised telescope within sheath and cold sterilised light cable (assistant will have drained, then rinsed with warmed sterile water).

    – Pick up cold sterilised camera and cables, ensuring that the plug is left untouched. The assistant will pick up the plug, unwrap any covering if present and walk to the tower to plug it in.

Putting Together the Instruments
  1. Endotip cannulae

    Screw the top on each port using firm pressure. Check seals are intact and in place. Check screw on gas valve is tight and close the valve.

    Remove pin and you can place this under the kit drape.

  2. Veress needle

    Screw both parts together.
    Check screw on gas valve is tight.
    Check spring action is working.

  3. Babcock forceps

    Babcock forceps into black outer casing. Once inserted twist the Babcock end 90 degrees to lock in place.

    Attach black handle on to the end – should just click into place. Use the handle with the ratchet to allow forceps to be locked in place.

  4. Metzenbaum scissors

    Close scissor jaws with fingers. Insert scissors into black outer casing, as with babcock forceps. Twist the end 90 degrees once inserted to lock in place.

    Attach black handle (the one without the ratchet) Has dial on handle to allow scissors to be oriented during surgery.

  5. Bipolar cautery

    Screw outer casing (silver) onto the cautery handle – must be done first before inserting forceps.

    Gently close the delicate cautery tips together with finger and thumb.

    Push button on top of handle and gently insert the cautery forceps insert into the outer casing and click into place. Don’t force the cautery insert.

  6. Camera

    Clip camera onto the telescope and attach the light cable.

    Turn on the light source, increase the intensity to at least 75% and white balance against a white swab.

Landmarks and Local Anaesthetic
  1. Cranial port

    The cranial port is placed halfway between the xiphisternum and the umbilicus.

  2. Caudal port

    The caudal port is placed 1cm caudal to the umbilicus. For patients with umbilical hernias the port placement is different and it is placed within the hernia.

  3. Local Anaesthetic

    Place 0.5ml bupivicaine as a bleb under the skin and another 0.5ml deeper into the underlying muscle tissue.

Placement of Veress Needle
  1. Stab incision

    Make stab incision just through skin with tip of 11 blade at site of cranial port

  2. Grasp abdomen

    Carefully grasp the abdominal wall on the midline at the umbilical area and elevate it without incorporating any intestine or spleen.

  3. Stab with needle

    Hold onto the grip of the veress needle (allowing the spring mechanism to work).
    Place the tip of the veress needle at 45 degree to the elevated abdominal wall (with your other hand) and penetrate through the stab incision and into abdomen. Ensure the needle is placed with the bevel pointing upwards.

  4. Ensure spring has released

    Ensure the spring has released, covering the needle tip with a blunt end.

  5. Insufflation

    Attach the insufflation cable to the veress needle and an assistant will turn the carbon dioxide flow on.

    The pressure should read low – around 1 to 4 mmHg.

  6. High Pressure?

    If the pressure is high then move the needle around gently and pull in and out slightly, carefully ensuring the needle is still covered with the blunt casing.

  7. 12mmHg

    The abdomen should insufflate until 12 mmHg is reached.

Placement of Caudal Port
  1. Protect bladder

    Ballot bladder at site of caudal port to ensure it is not pressed onto the body wall

  2. Scalpel incision

    Make stab incision full thickness through skin with tip of 11 blade at site of caudal port.

  3. Insert cannula

    Thread the endotip cannula (6mm) into the caudal incision and rotate clockwise. Rotate one to three full rotations to fully place intra abdominally.

  4. Check cannula

    Check entry to abdomen by pressure the spring-loaded valve on the port and you will hear a rush of gas.

  5. Remove veress needle

    Remove veress needle.

    Attach the insufflation hose to the caudal cannula and re-establish 12 mmHg if any pressure was lost.

Placement of Cranial Port
  1. Scalpel incision

    Make stab incision full thickness through skin with tip of 11 blade at site of caudal port

  2. Introduce cannula

    Use the camera to observe the area in which the port will enter to ensure that it avoids spleen and other organs: check that the viscera aren’t close to the port entry site and no tissue clinging to the body wall in that area. You can use a finger to press down over the cranial port entry site to ensure this.

    Gently enter the abdomen with the other 6mm endotip cannula turning clockwise. You can do this without the need for direct visualisation using the camera, however this can be useful to check how the port is advancing.

    This is what the surgeon observes on the screen:

Entering The Abdomen with Instruments
  1. Ground rules – camera first

    When placing instruments into the abdomen, be aware that the telescope must go in first. This is nearly always placed into the caudal port.

  2. Ground rules – instruments

    When entering with babcock forceps, scissors, cautery or any other instrument ensure the jaws are closed.
    Position the telescope so the other port is well visualised. Advance the instrument through the port until the tip of the instrument can be seen moving through the end of the port.

  3. Synchronous movements

    Move the instrument at the same time as moving the camera to ensure you always know where inside the abdomen it is.
    This helps prevent inadvertent touching of organs with any surgical instruments as they will always be in your view.

  4. Lost visualisation of the instrument?

    If your instrument goes out of view then withdraw it until the port and start again locating the cranial port and advancing the surgical instrument.

Locating and Securing Right Ovary
  1. Tilt

    Tilt patient to left and stand on the left side of the patient. Ensure that the surgical instruments on the trolley are easily accessible.

  2. Babcock forceps

    Pass the babcock forceps through the cranial port with the fixed jaw on the bottom.

  3. Locate ovarian bursa

    The ovary will be caudal to the caudal pole of the kidney.

    Look for the ovary in the area of the duodenum, lateral to the pancreas. The ovarian ligament is white and shiny. Once the ovary is visualised pass the bottom jaw of the babcocks through the bursa, which is red.

  4. Lift ovary

    Close the forceps and lock the ratchet. Apply traction to lift the ovary up towards the abdominal wall, away from other organs.

  5. Hook or needle placement

    Lift the ovary to the desired spot for the hook to pass through. The hook or needle should be placed to triangulate between the two ports.

    Tap the abdomen with a finger on the drape to see on the screen where the hook will pass into.

  6. Hook ovary

    Pass the needle or hook through the body wall and through the ovarian bursa, or use the forceps to place the ovary onto the hook.
    Do not pass the hook through any ovarian tissue.

  7. Withdraw forceps

    Once the ovary is secured let the forceps go and withdraw from abdomen.

Cauterising and Cutting Right Ovary
  1. Insert cautery forceps

    Pass cautery forceps through cranial port and direct towards the ovary that has now been tacked (watch cautery forceps enter the abdomen)

  2. Cauterise

    Cauterise suspensory ligament, blood supply and uterus. Use right foot on the pedal.

    When cauterising pull slightly away from body wall and ensure that you are not too close to any organs.

  3. Insert scissors

    Remove cautery forceps and replace with scissors (watch scissors enter the abdomen).

  4. Cut tissue

    Cut cauterised tissue-aim to leave some cauterised tissue behind.
    If bleeding occurs remove scissors and cauterise again.

  5. Check for haemorrhage

    Once ovary has been cut free from uterus check the ovarian pedicles for bleeding.

Grasping and Removal of Right Ovary
  1. Use babcock forceps to grasp ovary

    Enter the Babcock forceps into the cranial port and grasp the ovary that is attached to the hook.

    Once securely grasped remove the hook from abdominal wall.

    Babcock forceps should still have hold of ovary if locked in place, however to ensure 100% security keep a grip on the forceps.

  2. Remove Ovary

    Tilt table to middle position. Bring ovary to the cranial port site. You can remove cannula.

    Using artery forceps to help grasp the ovary you can then wiggle it free.

    Place finger over cranial port site to prevent too much gas escaping.

  3. Replace port and check ovary

    Replace cranial cannula. If site was enlarged use towel clamps to close gap around cannula.

    Check, using dissection if required, that the whole ovary has been removed.

Locating and Securing Left Ovary
  1. Tilt

    Tilt patient to left and stand on the left side of the patient.
    Ensure that the surgical instruments on the trolley are easily accessible.

  2. Babcock forceps

    Pass the babcock forceps through the cranial port with the fixed jaw on the bottom.

  3. Locate ovarian bursa

    Look for the ovary usually underneath the spleen, caudal to the caudal pole of the kidney.

    The spleen usually requires moving out the way, sometimes bluntly flipping it towards the camera.

    The ovarian ligament is white and shiny.

    Once the ovary is visualised pass the bottom jaw of the babcocks through the bursa, which is red.

    Close the forceps and lock the ratchet.

  4. Lift ovary

    Apply traction to lift the ovary up towards the abdominal wall, away from other organs.

  5. Hook or needle placement

    Lift the ovary to the desired spot for the hook to pass through.

    The hook or needle should be placed to triangulate between the two ports.

    Tap the abdomen with a finger on the drape to see on the screen where the hook will pass into.

  6. Hook ovary

    Pass the needle or hook through the body wall and through the ovarian bursa, or use the forceps to place the ovary onto the hook.

    Do not pass the hook through any ovarian tissue.

  7. Withdraw forceps

    Once the ovary is secured let the forceps go and withdraw from abdomen.

Cauterising and Cutting Left Ovary
  1. Insert cautery forceps

    Pass cautery forceps through cranial port and direct towards the ovary that has now been tacked (watch cautery forceps enter the abdomen)

  2. Cauterise

    Cauterise suspensory ligament, blood supply and uterus. Use right left on the pedal. When cauterising pull slightly away from body wall and ensure that you are not too close to any organs.

  3. Insert scissors

    Remove cautery forceps and replace with scissors (watch scissors enter the abdomen).

  4. Cut tissue

    Cut cauterised tissue-aim to leave some cauterised tissue behind. If bleeding occurs remove scissors and cauterise again.

  5. Please note

    When cauterising the left ovary, it is sometimes easier to focus cautery and cutting on the uterus before the suspensory ligament.

  6. Check for haemorrhage

    Once ovary has been cut free from uterus check the ovarian pedicles for bleeding.

Grasping and Removal of Left Ovary
  1. Use babcock forceps to grasp ovary

    Enter the Babcock forceps into the cranial port and grasp the ovary that is attached to the hook.

    Once securely grasped remove the hook from abdominal wall.

    Babcock forceps should still have hold of ovary if locked in place, however to ensure 100% security keep a grip on the forceps.

  2. Remove Ovary

    Tilt table to middle position.

    Bring ovary to the cranial port site. You can remove cannula.

    Using artery forceps to help grasp the ovary you can then wiggle it free.

    Place finger over cranial port site to prevent too much gas escaping.

  3. Replace port and check ovary

    Replace cranial cannula. If site was enlarged use towel clamps to close gap around cannula.

    Check, using dissection if required, that the whole ovary has been removed.

Final Laparoscopy and Wound Closure
  1. Check for haemorrhage

    Place finger of cranial port site to prevent gas escaping and have one last look inside using the camera and check both sides for bleeding.

  2. Desufflation

    Deflate abdomen and remove remaining cannula.

  3. Internal sutures

    Close the two port points muscle layer and fat with monofilament, synthetic, long half-life suture (polydioxanone or similar).

    Use a deep-superficial-superficial-deep technique. To do this grasp using rat-tooth forceps and insert needle on the deep side of the muscular surface, passing through to the superficial. Then the opposite movement on the opposing muscular layer.
    You will end up with a knot buried in the muscle tissue.

  4. Skin Glue

    Glue the skin wounds.