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Simulation

Laparoscopic Sterilization

Simulation

Preparation

Simulators to be Used

  • Laparoscopic box trainers will be used
  • Laparoscopic Maryland graspers, endoshears, locking grasper, Falope ring, or Filschie® clips, or a cautery device like Kleppinger bipolar device
  • Premade uterus (from the Laparoscopic ovarian cystectomy simulation) with regular ovaries

Materials

  • Laparoscopic box trainer
  • Maryland grasper, endoshears, locking grasper, Falope ring, or Filschie® clips, or a cautery device (like Kleppinger bipolar device)
  • Preconstructed uterus (from Laparoscopic ovarian cystectomy simulation)
  • Suture and alligator clamp/ notebook clip
  • Clown balloons - cut in half and one end cut to represent fimbriae
  • 5-inch balloons
  • Cotton
  • Kelly® type clamps
  • Gel hand sanitizer

Figures

Materials for the ectopic pregnancy simulation.

Simulated uterus, tubes and bilateral ovaries.

Figure 1 - Simulated uterus, tubes and bilateral ovaries
Simulated uterus, ovaries and right ectopic pregnancy.
Figure 2 - Simulated uterus, ovaries and right ectopic pregnancy.
Securing the uterus into the Laparoscopic Box Trainer. 
Figure 3 - Securing the uterus into the Laparoscopic Box Trainer.

To construct noncystic ovaries, place a cotton ball into a 5-inch balloon and knot the end.

Securing the uterus with the attached ovaries and tubes into the laparoscopic box trainer

  1. Place a chux pad in the box. Attach an alligator clip or paper binder to the back of the box with a string or suture
  2. The uterus will be secured in the box using only alligator clips, make sure it is fairly secure using the two clips at the top of the box on at the top of the uterus and the string added to the "uterine cervix." Some movement of the uterus is expected and desired
  3. Two accessory ports will be used to complete the task
Simulated attached uterus with ectopic pregnancy.
Figure 4 - Attached uterus with ovaries and fallopian tubes

Lab Sequence

  1. The laparoscopic box trainers will be set up as described in the preparation portion of the simulation exercise
  2. The learner will describe the process of a time out
  3. The learner will describe the proper positioning of a patient
  4. The learner will describe the proper set up of the camera equipment, tubing, and energy sources
  5. The learner will call for and identify the instruments used in the simulation: Maryland graspers, endoshears, and a locking grasper. To perform the occlusion of the fallopian tube the learner will call for and identify a Falope ring or Filshie® clips, or a bipolar cautery device like a Kleppinger device
  6. The learner also may call for what other instruments he or she may use in the actual operating room
  7. The learner will describe the method upon he/she would gain access to the abdominal cavity
  8. The learner discusses the method that he/she would choose to obtain appropriate pneumoperitoneum by Veress needle, Hassan method, direct trocar insertion, or left upper quadrant insertion
  9. The learner identifies and describes key surgical anatomy
  10. The learner then describes safe secondary trocar placement as needed
  11. The learner identifies and evaluates the fallopian tubes using the Maryland graspers and a locking grasper
  12. The learner grasps, positions, and orients the fallopian tube. Performs an occlusion of the fallopian tube using his or her method and instrument of choice. If a Kleppinger device is used, it should not be connected to electricity
  13. The learner is to simulate its use
  14. The learner will identify and discuss the proper technique to use to avoid injury to the ovary
  15. The learner describes securing hemostasis
  16. The learner then describes how he or she would confirm hemostasis
  17. The learner describes or performs irrigating and removing of blood and/or fluid
  18. The learner describes proper removal of trocars under direct visualization
  19. The learner describes the proper closure of the fascial defect after trocar removal
  20. The learner describes the proper closure of the skin incisions.

Competency Assessment

The resident will identify, select, and correctly use the appropriate laparoscopic instruments. The resident should be able to discuss how to control bleeding if encountered as well as the pros and cons of performing sterilization by different methods. The resident will be able to complete a laparoscopic sterilization.


Author

  • E. Britton Chahine, MD Assistant Professor, George Washington University