The surgeon marks the anteromedial and anterolateral joint lines and portal positions with a skin marker. 2. The skin areas for portal placement are infiltrated with local epinephrine. If the knee has an effusion, the surgeon aspirates it with a 16-gauge needle on a 60ml syringe, followed by injection of a small amount of distending fluid. 3. After a small stab incision with a #11 or #15 knife blade, the surgeon inserts the irrigation cannula and trocar into the lateral suprapatellar pouch near the superior pole of the patella.
Lactated Ringer’s or normal saline solution is connected to the cannula and the joint is distended using gravity or a pressure-sensitive arthroscopy pump. 4. A stab incision is then made laterally or medially 2-3 mm above the tibial plateau or patellar tendon at the joint line. A sharp trocar and sheath are inserted through the stab wound and just through the capsule. 5. A blunt trocar is used to pass the sheath into the knee joint. The surgeon removes the trocar and inserts a 30 or 70 degree scope into the sheath. The light source and video camera are connected to the scope. 6.
The inflow may remain in the suprapatellar area, and the tubing is connected to the arthroscope, or the position may be reversed. 7. A spinal needle can be introduced under direct vision to determine the best angle for an opposite portal for insertion of probes and operative instruments. The cruciates and menisci are probed to determine integrity and tears. 8. The scope is moved to the opposite portal to facilitate complete examination. 9. The joint is irrigated periodically and at the end of the procedure to maintain good visualization and clear the joint of blood and tissue fragments. 10.
Necessary repairs are made using special arthroscopic instruments, drills, shavers, or implants. 11. The surgeon closes the portals with nylon or undyed polyglactin suture and ? inch wound closure strips. 12. Local of surgeon’s choice (usually with epinephrine 1:200,000) may be injected intraarticularly to minimize bleeding and postoperative pain. Vaginal Hysterectomy Procedural Steps: 1. A patient is placed in lithotomy position, prepped and draped. 2. A weighted speculum is placed in the vagina for exposure. 3. A uterine tenaculum is passed to grasp the cervix and two hand held retractors are placed for additional exposure. . The anterior vaginal wall is opened with a transverse incision in the vesicovaginal layer of fascia. Space between vaginal wall and cervix is opened. 5. Bladder is dissected off the cervix and lower uterine segment anteriorly. Bladder is advanced on the cervix to vesicouterine fold. 6. Posterior vaginal wall is mobilized off the cervix by extending transverse vaginal skin incision posteriorly to encircle cervix. Cul-de-sac is entered and the incision extended to the ligaments, clamped, ligated, and incised at their attachment to the cervix. 7.
Uterosacral ligaments are exposed, clamped and doubly ligated bilaterally at their attachment to the cervix. Uterine vessels are clamped, incised, and ligated. 8. Bladder is retracted upward and cervix pulled downward. Peritoneal cavity is opened and uterine body is grasped, marking suture is placed on peritoneum. 9. Peritoneal incision is extended laterally until the anterior surface of uterine body can be delivered. Ovaries and tubes are inspected to determine if they need to be removed. 10. Round, ovarian, broad ligaments and fallopian tubes are clamped and ligated.
This is done bilaterally. Mobilization of the uterus continues until it is completely free. The uterus then is removed as the specimen. 11. Next the bladder flap is closed with a 2-0 absorbable suture then the peritoneum also with a running absorbable suture. 12. Excess peritoneum is dissected to a point in front of the rectum. Edges are approximated in the midline and sutured. 13. Additional sutures are placed anterior to the rectum to provide additional strength and support of the vaginal vault. 14. Peritoneal cavity is closed with a purse string suture.