Laparoscopic entry and complications — structured SAQ (15 marks)

(a) Choice of entry technique and insufflation pressure (3 marks)

One mark for technique justification, one for technique name, one for pressure target.

• Patient-specific risk: BMI 38 (obesity) and previous midline laparotomy for ovarian cancer — both increase the risk of adhesions to the anterior abdominal wall under the umbilicus, and obesity increases the depth of the abdominal wall.^[1]
• Technique choice: Open Hasson at the umbilicus with adhesiolysis under direct vision is the RANZCOG C-Gyn 7 default for the patient with previous midline surgery. Palmer's point Veress insertion (left upper quadrant, 3 cm below the costal margin in the mid-clavicular line) is the alternative when the umbilicus is hostile.
• Insufflation pressure target: 12–15 mmHg in routine practice; aim for the lower end (12 mmHg) in obese patients to allow adequate working space with reduced cardiopulmonary compromise.

(b) Recognition and management of preperitoneal insufflation (4 marks)

One mark for recognition, one for immediate response, one for repositioning plan, one for proceeding safely.

• Assessment: a small (under 5 mm) full-thickness small bowel injury with no significant contamination — accessible to laparoscopic repair; inspect the entire small bowel and the rest of the abdomen for additional injuries.^[1]
• Immediate response: stop insufflation, disconnect the CO2 line, withdraw the Veress needle; do not force.
• Repositioning plan: in this patient with previous midline surgery, the safest next step is to abandon the umbilical approach and use Palmer's point Veress insertion in the left upper quadrant, or convert to open Hasson under direct vision.
• How to proceed safely: confirm intraperitoneal placement by low initial pressure rise with 1.5–2 L delivered, sliding sign on the laparoscopic camera, and visualisation of bowel and omentum; do not insert the primary trocar until position is confirmed.

(c) Recognition and management of gas embolism (4 marks)

One mark for each of: recognising the syndrome, immediate four moves, support and aspiration, post-event plan.

• Recognition: sudden hypotension with a falling end-tidal CO2 (the anaesthetist will call it first), cyanosis, and a mill-wheel murmur on auscultation, in temporal relationship to insufflation. Differential includes anaesthetic overdose, anaphylaxis, haemorrhage, pulmonary embolism and high spinal — but the temporal relationship and the mill-wheel murmur are diagnostic.^[1]
• Four-move immediate resuscitation: (1) stop insufflation, (2) deflate the pneumoperitoneum, (3) place the patient in the Durant position (left lateral and Trendelenburg to trap gas in the right ventricle), (4) give 100% oxygen and aspirate a central venous catheter if present.
• Support: large-bore IV access, fluid resuscitation, advanced life support with CPR if arrest.
• Post-event plan: declare the critical incident, document and report, anaesthesia-led debrief, neurological and cardiovascular observation.

(d) Management of intraoperative bowel injury (4 marks)

One mark for assessment, one for repair plan, one for antibiotics and consult, one for postoperative plan.

• Assessment: a small (under 5 mm) full-thickness small bowel injury with no significant contamination — accessible to laparoscopic repair; inspect the entire small bowel and the rest of the abdomen for additional injuries.^[1]
• Repair plan (Lund / McKernan ladder): laparoscopic single-layer or two-layer repair with absorbable suture (e.g. 3-0 PDS), seromuscular for the second layer if a two-layer technique is used; inspect for luminal compromise; check for bleeding.
• Antibiotics and consult: prophylactic broad-spectrum antibiotics (e.g. cefazolin + metronidazole, or co-amoxiclav), intraoperative general surgical consultation if available or after repair if not, take an image of the repair for documentation.
• Postoperative plan: enhanced observation with low threshold for return to theatre if the patient deteriorates (tachycardia, fever, abdominal pain, ileus, falling haemoglobin), VTE prophylaxis, discharge counselling on warning signs.