This checklist is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

The pdf form of the Checklist for General Laparoscopy may not contain the latest changes below

Preoperative Checklist

(Please indicate - Done, X - Not done, NA – Not applicable)

  1. ____ Inform patient about possible complications from surgery and need for further surgery or treatment to address any complications (inability to visualize, bowel injury, bladder injury, ureter injury, bleeding, preperitoneal CO2, incisional hernia
  2. ____ Perform preoperative mechanical bowel prep (prevent bowel injury) (prevent inadequate visualization)
  3. ____ Be familiar with open laparoscopy techniques and left epigastric/left upper abdominal insufflation and small (5mm) laparoscope insertion
  4. ____ Be aware of smoke evacuation techniques (prevent inadequate visualization)
  5. ____ Be aware of techniques to clean lens without removing laparoscope from abdomen (prevent inadequate visualization)
  6. ____ Be familiar with the safer insertion points for trochars to avoid bleeding of inferior epigastric vessels (prevent bleeding complications)

Intraoperative Checklist

  1. ____ Determine version and flexion position of the uterus (prevent uterine perforation)
  2. ____ Gently sound uterus (prevent uterine perforation)
  3. ____ Gradually dilate internal uterine os to size of uterine manipulator (prevent uterine perforation)
  4. ____ Set guard on uterine manipulator so length of manipulator does not exceed uterine sounding depth (prevent uterine perforation)
  5. ____ Avoid previous midline/vertical abdominal incisions for Verees and trochar placement (prevent bowel injury)
  6. ____ Make incision the correct size for trochar so as to avoid CO 2 loss (prevent inadequate visualization
  7. ____ Cauterize skin incision bleeding of trochar sites before proceeding with Veress or trochar placement (prevent hematoma)
  8. ____ If closed insertion of umbilical trochar is used,
    1. ____ check for correct working mechanism for safety shielding of trochar point and blunt trochar of Veress needle (prevent bowel injury)
    2. ____ Feel for Verres needle tip free mobility after inserting (prevent preperitoneal CO2 insufflation)
    3. ____ Do not continue insufflating gas if pressure is >10mmHg or flow rate is less than 1.0 ltr/min (prevent preperitoneal CO2 insufflation)
    4. ____ Hub of trochar needs to remain in saggittal midline plane at a 45-60 degree angle pointed toward the pelvic hollow. (prevent large vessel injury)
  9. ____ Check omentum for bleeding after entry.(prevent postoperative bleeding)
  10. ____ Insert lateral trochars at safe locations (>6cm from midline) and with intraabdominal laparoscopic visualization to avoid inferior epigastric vessels (prevent bleeding)
  11. ____ Identify and avoid key structures (by 2-3 cm) when cauterizing/lasering (prevent cautery injury)
  12. ____ Close fascial defects away from the midline if greater than 5 mm and midline defects if > 10-11 mm (prevent postoperative dehiscence/hernia)

Signature: _________________________ Attending:_____________________ Date:______

Global Evaluation: |Initial learning| |Needs work| |Progressing| |Good for level| |OK on own|

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