Tips and Tricks in Laparoscopic Surgery – Port Placement

Video 4 Tips and Tricks in Laparoscopic Surgery – Port Placement  Introduction This is my 4th video in the series Tips and Tricks in Laparoscopic Surgery. In this Video I am going to look at different ways of Port placements. Whenever I teach laparoscopic suturing, the first question I ask my students is “what is your preferred port placement”. There is no point learning how to suture with one port placement and go back to perform surgery with a different port placement. So deciding on which is your preferred port placement is important before embarking on laparoscopic surgery. In this video I will discuss the different types of port placements and their advantages and disadvantages. In the discussion that follows, I am assuming that the surgeon is right handed and stand on the left side of the patient when performing laparoscopic surgery. A. 3 ports strategy. Besides the camera port, 2 other ports are placed to perform the surgery. The

Surviving Private Practice in Malaysia – Clinic systems in Private Hospitals

Private Hospitals in Malaysia Since the 1990’s private hospitals have mushroomed in Malaysia. In 2018 the total number of private hospitals in Malaysia was reported as 240 as opposed to 144 government hospitals. The biggest groups of hospital are KPJ (27), Pantai /Gleneagles (15) and Columbia Asia (13).  How we started in Mahkota Medical Centre In 1994 I joined a brand new hospital called Mahkota Medical Center, Melaka. It was originally built and owned by the Lion’s Group. Dr. Jack Chiang a Taiwanese hospital builder was employed by the Lion’s Group to build this hospital. It was build based on the Taiwanese concept whereby everything was owned by the hospital. The doctors just walk in and work for a percentage of the procedure fees. This was a new concept in Malaysia All other private hospitals had a system where the doctor’s charge is separate from the hospital charges.  In this new system the doctor gets 1/3 of all procedures charged

Tips and tricks in performing laparoscopy – Different techniques of insertion of the first trocar

Different laparoscopic surgeons have different ways of inserting the first trocar. Here I will outline what I have seen and what is my preferred technique of first trocar insertion. 1. How do you insert the 10mm trocar without carbon dioxide insufflation There are 2 ways  I have seen of inserting the 10mm trocar without carbon dioxide insufflation. They are: Using a visiport Using a reusable trocar Using an optical trocar Here an optical trocar is used with a laparosocope in it. The trocar is advanced into the abdomen while visualizing the tissues being separated as you rock the trocar from side to side. I have only seen this being done from the umbilicus. I am not sure whether anyone has tried this on a skin incision above the umbilicus but technically I think it is still possible. Using a reusable trocar I have seen Prof. Arnaud Wattiez placing the trocar directly into the abdomen without carbon dioxide insufflation. Here an incision

Laparoscopy – Tips and tricks in performing laparoscopic surgery – Carbon dioxide insufflation and the first trocar insertion

This is my second video in the series of Tips and Tricks in performing laparoscopic surgery. I will be talking about carbon dioxide insufflation and insertion of the first trocar during laparoscopic surgery. I already have a video entitled Complications in Laparoscopic surgery so I will not repeat what I have already discussed in that video. I will discuss on some questions frequently asked by my trainees and Fellow on carbon dioxide insufflation and first trocar insertion. 1. Check your Verres needle  This is an important step. Make sure you personally check that the insert and the sleeve match. The Verres needle has 2 parts, the outer sheath which has a sharp end and the inner part, which is spring, loaded. They are of different lengths. Sometimes the outer sheath is assembled with the wrong inner sheath. It is very dangerous when the inner sheath is shorter that the outer sleeve as the outer sleeve is not protected by the inner

Laparoscopy – Tips and tricks in performing laparoscopic surgery

I have been doing laparoscopic surgery for about 25 years. I have visited many famous laparoscopic surgeons and learnt from them. There are many tips and tricks I have learnt over the years. I wanted to write a book on athis topic but that will take a long time. I have decided to blog all my thoughts. In this was it could be always updated. The aim of these series of blogs is to educate young doctors keen on learning laparoscopic surgery. My plan is to make videos to accompany this blog so that learning will be more fun. I will be grateful if experts in laparoscopic surgery could give me pointers on improving these blogs as well as give other tips that will benefit everyone. You can follow all the videos and blogs by clicking #laparoscopytips. Bowel preparation There is controversy as to whether bowel preparation should be done before laparoscopic gynaecological. My personal policy is that, I don’t

Laparoscopy- 14 steps to improve your skills in Laparoscopic surgery

Early days When I was training as a Registrar in the Obstetrics and Gynaecology Unit at Hospital Sultanah Aminah, Johor Bahru, between 1988 and 1991 the only laparoscopy we did was diagnostic laparoscopy and laparoscopic tubal ligation using the Falope ring.  UK  I went on to work in a small hospital in the UK.  Very few surgeries were done by laparoscopy in that hospital. One of my consultants was starting to do some hysteroscopic surgeries at that time. Specialist in OBGYN On returning from the UK, I became a specialist at the same hospital. This was the time went the hospital acquired a video laparoscopy system. The general surgeons were doing laparoscopic cholecystectomy and I frequently watched them struggling with this surgery. I was trying out simple surgeries by laparoscopy which includes laparoscopic salpingectomy for ectopic pregnancies and simple laparoscopic cystectomies. We had several consultants from the National University Hospital, Singapore who used to come and do laparoscopy cases with us. I learned from them. Training in

Poor assistants, poor equipment and no Mentor when performing surgery by laparoscopy.

In one of my earlier blogs entitled “12 reasons why laparoscopic surgery is not popular in Malaysia”, the 9th reason I stated was “You don’t get good assistants when performing surgery by laparoscopy” This is a common complaint by gynaecologist keen to perform laparoscopic surgery. Laparoscopic surgery is an instrument intensive procedure. You need nurses who can prepare all the necessary equipments to perform the surgery. Even if one item is missing, it will be difficult to perform the surgery. For example, recently I performed 2 total laparoscopic surgeries on very large uteruses measuring more than 1 kg. The suction irrigation system was not working properly and it took a longer time for me to complete the surgery. The importance of nurses  It is difficult for a gynaecologist to be present in the operating room to make sure that all the equipments are there before starting the surgery. This is the job of the nurses. Once the instruments are prepared, the

12 reasons why surgery by laparoscopy in gynecology is not popular in Malaysia

I have been performing surgery by laparoscopy surgery for more than 25 years. Unfortunately, the progress made in surgery by laparoscopy in gynaecology in Malaysia is very slow. These are the reasons I think why gynaecologists in Malaysia perform so few surgeries are performed by laparoscopy. You don’t get paid extra for performing Surgery by Laparoscopy Malaysian Private Health Care Act 1998 states that the fees that can be charged for a procedure is the same whether it is performed by laparoscopy or laparotomy. This means that if I were to perform a hysterectomy by an open laparotomy, vaginally or by laparoscopy, the doctor’s fees is the same. Surgery by Laparoscopy in gynaecology requires extra skills. It takes a long time to acquire these skills and the surgery takes a longer time to perform. Off course the benefits to a patient when undergoing surgery by laparoscopy compared to laparotomy are enormous. When the remuneration is the same, most gynaecologist do

Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis

Single incision (laparoscopy) laparoscopic surgery using the Hakko E-Z Access and lap protector