Lost Needle in a Robotic Case – Pointers for Prevention and Retrieval

Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 Study Objective: To utilize a laparoscope cannula designed with an embedded mechanism to clean and wipe the lens of the laparoscope while inside the abdominal cavity. Design: The mechanism is designed along the wall of a standard cannula. The mechanism consists of a flapper which can be actuated, locked and unlocked mechanically by the assistant holding the scope. A water and vacuum channel is embedded inside the wall of the cannula. The flapper is provided with a silicone rubber to wipe the lens. Setting: Galaxy Care Laparoscopy Institute, India. Patients: The instrument was tested on 10 patients spanning from short duration surgical procedures like laparoscopic cholecystectomy to longer duration laparoscopic procedure like radical hysterectomy. Intervention: To start cleaning, the scope is withdrawn by less than an inch; the flapper is actuated and locked. Once the flapper is actuated, the water flows along the embedded channel and sprays on the lens, also creating a pool to rinse and clean the lens. The vacuum suctions out the water from the cannula. The silicone rubber on the flapper is used to clean the lens. Later, the flapper position is unlocked and brought to rest position, thereby completing the cleaning procedure. Measurements and Main Results: The mechanism saves an average of 8% of surgery time, moreover allowing the surgeon to continue operating with less disruption. Conclusion: The lens cleaning mechanism embedded within the cannula allows faster cleaning of the lens without having to withdraw the entire scope out of the cannula. This results in more focus on critical surgeries and reduces the duration of a laparoscopic procedure, hence reducing the cost. 526 Lost Needle in a Robotic Case – Pointers for Prevention and Retrieval Syed R. Ob/Gyn, Staten Island University Hospital, Staten Island, New York Study Objective: The objective of this case study is to raise awareness of special scenarios which may arise with Robotic assisted surgery. Design: Clinical Case Presentation of a Robotic Case. Setting: Private Practice patient and retrospective case study. Patients: This is a 30 y/o G0P0 who presented to the office with a painful large fundal myoma 10cm in size.She was scheduled for Robotic assisted lap Myomectomy.The Myomectomy and repair of the uterine defect which lasted 1 1/2 hrs was uneventful.At the last exchange of needle between surgeon and PSA,needle was dropped and could not be found! Intervention: The Robot was undocked and intensive search for needle took place laparoscopically.C-Arm search took place and needle was visualized fluroscopically near the spine.First consult with a general surgeon failed.Second surgeon’s attempt succeeded in finding the needle after 2 1/2 hrs later. Measurements and Main Results: This case study involved one patient with an unusual complication.The procedure took place in a University hospital using DaVinci Robot SI. OR time 6hrs console time 1 1/2 hrs Search for needle-2 1/2 hrs Morcellation of specimen 45 mts EBL=100ml Hospital stay-1day Needle was removed and patient went home following day. Conclusion: The OR time was prolonged and unnecessary intraoperative intervention with C-arm and surgical consult took place.Fortunately the needle was found and removed intact from the body.Strategies for prevention of such an event and pointers for recovery of needle will be presented. 527 A Major Vascular Injury with a New Motorized Morcellator Thoughts on Etiology and Prevention Syed R. Ob/Gyn, Staten Island University Hospital, Staten Island, New York

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Study Objective: To raise awareness of using New instrumentation which may come with nuances which need to learned before use to avoid injury. Design: A Retrospective case study of a Major Vascular complication during Robot Assisted Lap Supracervical Hyst where a morcellator injury took place. Setting: A private practice patient who underwent surgery in a University Hospital. Patients: This 53 y/o P3003 patient,postmenopausal with a recent VATS surgery for early Lung Ca presented with request for Robotic surgery for Uterocervical prolapse.Patient underwent an uneventful RALSHBSO and Y mesh augmented sacrocervicopexy with 70cc EBL.The small fundus of the uterus needed morcellation.The senior resident left on a personal errand.Junior resident handled a NEW morcellator before surgeon could visualize and caused avulsion injury to Rt Iliac artery and vein and IVC. Intervention: Surgical and Vascular consults were called aftyer laparotomy.7 units PRBC and 3 units FFP and 8000cc crystalloids were given during repair.Pt was admitted for 4 days to ICU and stayed a total 13 days in hospital. Measurements and Main Results: Patients surgery took total 7 1/2 hrs Laparoscopy and Docking of Robot1 hr Surgeons console 2 1/2 hrs Attempted morcellation and repair of vascular injuru with Laparotomy-4hrs ICU stay4days Hospital stay 13days 7 units PRBC/3units FFP Developed DVT on 6th po day and had to get IVC filter Discharged on Lovenox. Conclusion: The Hospital substitutions of instrumentation (as newer and cheaper ones come in the market) MUST be preceded by evaluation prior to its FIRST use in the OR.Residents MUST be trained and educated in ALL the technology of modern surgery.Such a devastating injury could be totally prevented.Succinct recommendations will be presented. 528 A Simplified Standardized Technique for LESS (Laparoendoscopic Single Site Surgery) Hysterectomy: Experience with over 300 Cases Wagner J,1 Saraf S,2 Fridman D.3 1Huntington Hospital, Huntington, New York; 2Maimonides Medical Center, Brooklyn, New York; 3Albert Einstein College of Medicine, Bronx, New York Study Objective: To describe our technique for LESS hysterectomy. Design: Retrospective evaluation of the surgical technique used to perform more than 300 hysterectomies utilizing LESS as the primary surgical approach. Setting: Single surgeon in a Northeastern community-based hospital practice. Patients: All patients undergoing laparoscopic hysterectomy. Measurements and Main Results: This is a summary report of our LESS technique and surgical principles. Instruments    

Right angled light connector Extra long instruments 30degrees 5mm bariatric length laparoscope Single incision port: SILS port (Covidien), Gelpoint (Applied Medical)  Kleppinger forceps and 45 cm Harmonic ACE scalpel (Ethicon) Surgical Principles/ Technique  Open Hassan technique for abdominal entry  Uncluttered surgical field  Attention to direction of extra-abdominal hand movements in addition to intra-abdominal instrument movements  Laparoscopic trocars in same horizontal plane.  Prevent sword fighting by sequentially placing one instrument at a time: 1. Camera in lateral trocar- visualize the specimen 2. Laparoscopic tenaculum in lateral trocar – to manipulate and expose the uterus