Safe Laparoscopic Access: technologies and techniques

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Safe Laparoscopic Access technologies
andtechniques

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• 96-1-2

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Laparoscopic Abdominal Entry

• Laparoscope-related complications were reported
  with increasing frequency during growing phase of
  laparoscopic surgery.
• Entering the abdomen is the most dangerous part
  of the laparoscopic procedures.

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Laparoscopic complications

• Complications
• general-anesthesia-related
• injuries to the vascular system, bladder, and
  bowel.
• These injuries
• indirect injury due to the use of monopolar
  current
• now more commonly ascribed as direct trauma
  caused by the insertion of the insufflation
  needle or the primary or secondary trocars
• Injuries occur more frequently as a result of the
  placement of the insufflating needle or primary
  trocar placement.
• Levy BS 1985 Reich H 1995

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Laparoscopic complications

• Most complications during laparoscopy occur
  during the surgeons first 100 cases.
• Soderstrom RM et al.
• Operative Laparoscopy The Masters Technique.
• 1993

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Laparoscopic Abdominal Entry

• Approaches to initial cannula
• Closed insertion without preinsufflation
• Closed insertion with preinsufflation
• Open laparoscopy

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Superficial anatomy of the anterior abdominal wall
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Anatomic landmarks

• Umbilicus at the level of L3 and L4
• Abdominal aorta bifurcation L4 and L5

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Placement of the Veress needle

• Umbilical area
• Lower edge
• Adequate size

• Complete horizontal position

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Placement of the Veress needle

• The angle insertion 45 degree from the surface
  of skin, more vertical orientation in obese women
• Aim toward uterus
• Aim away from pelvic vessels (vertical sagital)
• Aim at right angle to the skin

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Placement of the Veress needle

• Palpating the aorta and sacral promontory
• Grasp the base of umbilicus keep Veress needle
  from the abdominal structure

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Placement of the Veress needle

• Using towel clips to elevate the abdominal wall

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Tests of peritoneal insertion

• Drop test (Epidural space test)
• - a drop of water --- suctioned into
• peritoneal cavity
• Syringe barrel flow test
• Manometer test (free flow of gas)
• - elevation of abdominal wall, falling
• insufflation pressure ( lt 5-6 mmHg at
• 1.0L/min flow )
• Loss of liver dullness early in insufflation

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Tests of peritoneal insertion

• Aspiration-instillation-aspiration test (Syringe
  aspiration test)
• - Aspiration blood, bile, bowel content,
  urine
• - Instillation 10cc N/S--- if any
  resistant
• - Re-aspiration no fluid aspirated
• Waggling test (Lateral needle swing test)
  (potentially dangerous)
• - base on tactile confirmation of a free-
• moving tip
• - pivot point at the tip --- adhesion or pre-
• peritoneal
• - pivot point at the fascia ---
  intraperitoneal

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Tests of peritoneal insertion
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Tests of peritoneal insertion
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Recommended amount of gas for initial
insufflation with a Veress needle
Monaghan 2-4 L
Sutton About 3 L
Gordon 1-2 L
Soderstrom Pressure (not specified)
Deprest Brosens Preset pressure (not specified)
Bruhat Not specified
Hulka Reich 20-25 mmHg
Tompson Rock Should not exceed 10 mmHg
Tulandi 2-3 L (usually)
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Primary trocar insertion

• Patient in a horizontal position
• Skin incision should be large enough to prevent
  any resistance
• A stretched middle finger can prevent
  over-insertion (palming technique)
• Z-technique ? (prevention of incision hernia)

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Primary trocar insertionZ-technique
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Direct trocar insertionwithout preinsufflation

• First described by Dingefelder (1978)

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High risk conditions for abdominal entry

• Strong abdominal musculature (sportswomen)
• Body weight is obese or very thin
• Large pelvic mass
• Pregnancy
• Previous abdominal and pelvic operations

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In Morbid Obese Patients
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The Incidence of Adhesions After Prior Laparotomy
? (N360)

• Adhesion bowel omentum
• Pfannenstiel 13 87
• Midline below the umbilicus 17
  83
• Midline above the umbilicus 40
  60
• Subjects with all types of incision
• Gynecologic (42 ) gt Obstetric (22)
• Brill AL Obs Gyn 1995, 85269-72

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Management of abdominal wall access with
probable intraperitoneal adhesion

• Exploratory syringe aspiration test
• Direct Veress needle with optic catheter
• Open laparoscopy
• Alternative access

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Exploratory syringe test(Syringe aspiration
test)

• To ascertain no bowel/vessels adherent under
  the umbilicus before trocar insertion
• After pneumoperitoneum created by Veress needle,
  a 20-gauge needle inserted under negative
  pressure at the four cardinal points of a 20-mm
  circle around the umbilicus ---
• alternate sites trocar if blood or bowel
  content is aspirated

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Direct Veress needle insertion with optic
catheter ( needle scopy)

• 1.2mm, 1.75mm, 1.98 mm
• Visual control via optics inserted into
• needle

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Open laparoscopy

• 1971, Hasson
• A horizontal/vertical incision about 2 cm
• Enter peritoneal cavity by incision of abdominal
  wall step by step
• Apply Hasson trocar-cannula and purse-string
  suture at fascial level

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Open laparoscopy
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Alternative access sites

• inter/infracostal area
• - the 9th intercostal space in the middle of
  the mid-clavicular the ant axillary line
• Lt costal margin
• - 3-4 cm below the left costal margin in the
  mid-clavicular line
• - Reverse Trendelenburg position
• - First to rule out splenomegaly or
  insufflated stomach ( on NG )

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Alternative insertion sites
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Alternative needle insertion sites

• Lt periumbilical area
• - midclavicular line
• Transvaginal insertion
• - via post cervix fornix, trendelenburg
• position
• Transabdominal insertion
• - Pushed uterus up against the abdominal,
• then inserted through abdomen and into
• fundus of the uterus

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Alternative access -
the Lee-Huang point
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Storz TERNAMIAN EndoTIP ( Endoscopic Threaded
Imaging Port )

• Re-usable trocar
• After umbilical incision and Veress insufflation,
  a 0 laparoscope is mounted in the cannula. The
  tip of the cannula is inserted into a tiny
  fascial incision and rotated clockwise
• All the abdominal wall layers are well
  visualized

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Blunt Trocar

• is used to safely create a Pneumoperitoneum in
  the scarred abdomen
• fascial incision should be 1 to 1.5 cm in size
• A long suture is placed on each fascial edges
• finger dissection a tunnel or an opening into the
  intraabdominal cavity is gently created
• The foamgrip anchoring device is set and secured
  with the previously placed suture

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VISIPORT

• A 1 cm skin incision
• A telescope is inserted into the trocar and the
  path of entry of the trocar into intra-abdominal
  cavity is visualized
• These planes are cut slowly with the blade of the
  trocar (at the tip of the instrument)
• Pneumoperitoneum must be created or abdominal
  wall elevation must be performed prior to the
  insertion

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VERSASTEP SYSTEM

• an integrated system combining a Nylon
  stretchable sheath over a Disposable Veress
  needle
• Once inserted, the sheath is dilated by inserting
  the trocar (with a dilator in place)
• no cutting entry blade
• decreasing trocar site bleed and the potential
  for an intra-abdominal injury
• creates a smaller fascial defect which does not
  need to be closed
• up to 12mm

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VERSASTEP SYSTEM
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Secondary trocar insertions

• Off the midline, to the left, above the pubic
  hairline
• Transillumination and under endoscopic direct
  vision helps to identify the vessels.
• and minimizing the risk of injury
• Deep Inferior epigastric lt-- ext. iliac
• Superficial epigastric lt-- femoral
• Lateral to the rectus abdominis muscle
• Lateral to the umbilical ligaments
• Lateral to the deep epigastric vessels
• Aiming toward the uterus (cul-de-sac) and away
  from the iliac vessels
• Keeping the forefingers extended on the sleeve

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Conclusion - 1

• The incidence and spectrum of access-related
  complications is greater than previously
  perceived.
• Newer devices and modifications in technique may
  reduce the incidence of such adverse events.

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Conclusion - 2

• Put patient in a proper position
• Understand anatomical relation
• Follow the abdominal entry principles
• Be aware of high-risk conditions
• Use proper instruments and alternative strategies

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Q 1

• The angle insertion of Veress needle
• ? degree from the surface of skin ( more
  obese)
• 1. 30 degree
• 2. 45 degree
• 3. 90 degree
• 4. 0 degree

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Q 2

• What vessel injury related to peritoneal hematoma
  during lat. trocar insertion ?
• 1. Superficial circumflex iliac a.
• 2. Superficial epigastric a.
• 3. Deep circumflex iliac a.
• 4. Deep inferior epigastric a.