The K-code in laparoscopic hysterectomy, a novel approach to communicate in the surgical suite in the era of minimally invasive surgery. Introduction of endoscopic surgery to the various surgical disciplines accelerated the pace of innovation and technological advancement. Recent additions to our surgical armamentarium are high-definition 3D and infrared cameras, and robotic jointed arms with infinite precision and stability that translated to major improvement in surgical outcomes. Despite these advances in technology, little has changed in the paradigm of surgical team communication. Robotic assisted laparoscopy overcame the need for a camera assistant, but other assistants remain essential. Surgical assistants anticipate explicit verbal instructions to help coordinate camera views and mobilize organs and tissue. Poor communication in the operative suite is associated with longer operative time and increased blood loss. An additional challenge faced in medical centers is the utilization of residents in training for surgical assistants, often with high turnover rates. A surgical assistant's lack of experience increased the potential for communication errors and that in turn may increase the risk of adverse surgical outcome and contribute to surgical frustration. Communication in laparoscopy is challenging in part due to the fulcrum effect of both the trocars and the uterine manipulator. That renders directional commands more complex and confusing. The safety protocols borrowed from the aviation industry have helped leverage healthcare safety and efficiency standards over the past decade. Aviation resolved human-to-human communication errors by codifying and standardizing communication language, using predefined and straightforward tasks, cross-checking, and mandatory training of non-technical skills. Here we present a novel educational communication tool to standardize and codify surgical exposure during laparoscopic hysterectomy. This new approach may render communication with surgical assistants more uniform, clear, and efficient. Potential advantages to adapting this communication tool are, decreased communication errors related to the fulcrum effect and directional commands, decreased frustration with new assistants and enhanced surgical flow, decreased operative time and surgical adverse outcome. The K-code concept is based on the hypothesis that the laparoscopic views necessary for completion of a benign simple laparoscopic hysterectomy can be predefined and codified into eight basic views. For optimal exposure of those views, the uterine manipulator will need to be adjusted in harmony with the laparoscopic visualization. For example, I usually start the hysterectomy with dividing the left round ligament. For that, I would request the A1 view and the camera assistant will need to adjust the camera to the left upper quadrant. The criteria for the A1 view as demonstrated in this diagram are that the left round ligament should be taught and bisects the view and the anterior bladder reflection is visible in continuation with the round ligament. To fulfill these criteria, the uterine manipulator assistant will move the handle up and to the left side of the patient as demonstrated and broken down by these two figures. The K-Code concept is introduced through a PowerPoint presentation prior to surgery to the assisting staff. Presentation takes about 10-15 minutes. The presentation includes review of laparoscopic anatomy, review of laparoscopic views concept and diagrams, uterine manipulator navigation tips and diagram. In surgery, prior to starting the procedure, cross-checking of the different views is done with the assistants. Here's the A1 view, the A2 view, the A3 view, and then we move to the posterior views, the P1 view, the P2 view, and with every view you can zoom in and zoom out, and here is the P3 view. Once cross-checking is done, then the hysterectomy can start. Here we will demonstrate how the K-Code functioned the laparoscopic hysterectomy. We start with division of the left round ligament and use the A1 view for that step and then the anterior bladder flap and colpotomy exposure through the A2 view, and then the A3 view will help complete the division of the right round ligament. Now we move to the posterior views, the P3 view, which can be used to divide the right infantibular pedipedic ligament or perform the right self-injectomy or also divide the right utero-ovarian ligament, as shown here. This is the right view or the R view to divide the right uterine artery pedicle. A 30-degree camera might help optimize this visualization, especially in bulky uteruses. Here's the P1 view, the same concept of the P3 view, yet on the other side, and here we request the P2 view to delineate the posterior colpotomy area, and finally, the L view for division of the left uterine artery pedicle. The surgical assistance role requires the individual to be able to speak the language of the surgeon and see the surgical procedure through the surgeon's eyes. The K-code is a model for communicating during laparoscopic hysterectomy that uses a language that is easy to teach, remember, and utilize. The code also functions as an educational tool for the surgeon-in-training and the novice surgical assistant. Future research to study and verify the K-code influence and parameters of surgical success, surgical team satisfaction and engagement is needed. Thank you.

K-code

laparoscopic hysterectomy

communication

surgical team

operative time