Alternative ways of entry: different techniques to go into the abdominal cavity safely

Laparoscopy is a type of minimally invasive surgery with known advantages over laparotomy: reduced risk of any adverse effect of surgery, reduced pain and fewer days in hospital. Access to the abdominal cavity is the first challenge, as at least 50% of gastrointestinal and major blood vessel complications occur during the first umbilical trocar insertion. For this reason it is fundamental to know the anatomy of the abdominal wall in order to safely place the trocars during laparoscopic surgery.

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Alternative ways of entry: different techniques to go into the abdominal cavity safely

Authors

A Wattiez, J Leroy, A Vázquez Rodriguez, E Faller, J Albornoz, P Messori

Abstract

Laparoscopy is a type of minimally invasive surgery with known advantages over laparotomy: reduced risk of any adverse effect of surgery, reduced pain and fewer days in hospital. Access to the abdominal cavity is the first challenge, as at least 50% of gastrointestinal and major blood vessel complications occur during the first umbilical trocar insertion. For this reason it is fundamental to know the anatomy of the abdominal wall in order to safely place the trocars during laparoscopic surgery.

Catégorie

live recorded

Mots-clés

Ways of entry, entry access, abdominal cavity, Palmer's point

Type de vidéo

Vidéo chirurgicale

Durée

17'49''

Publication

2012-01

Popularité

Favoris

Favorites Media

Audio

E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3557.htm

Alternative ways of entry: different techniques to go into the abdominal cavity safely

1. Anatomical landmarks of the abdominal wall 00'12''

The most important landmarks are both anterior iliac spines, rectus muscles and inferior epigastric vessels. Safe areas for trocar placement are the lateral aspects of the epigastric vessels and the midline between the rectus muscles.

2. Veress needle entry: traditional way 01'48''

The use of a Veress needle to induce the carbon dioxide pneumoperitoneum for laparoscopy was made popular by Raoul Palmer in 1947. It is currently the most widely used technique by gynecologists worldwide to access the abdomen.

3. Umbilical incision and needle placement 02'40''

An intraumbilical skin incision is made parallel to the abdominal wall, and the Veress needle is then placed inside the incision with the carbon dioxide valve opened, in a 90-degree angle in relation to the position of the fascia.

4. Veress needle insertion 03'26''

The abdominal wall is lifted up below the level of the umbilicus and the operator observes how the angle of the Veress needle changes. The 90-degree angle in relation to the fascia is kept. A gentle push is then performed until a loss of resistance is felt. This means that the tip of the needle is inside the abdominal cavity.

5. Safety tests to confirm intra-abdominal placement 04'09''

A safety test should be carried out every time. An empty syringe is placed into the Veress needle and aspiration is carried out. Normally negative intra-abdominal pressure should be found. The abdominal cavity is then insufflated with 20 cc of air and aspiration is again performed. If the needle is correctly placed, negative intra-abdominal pressure should be found again. The CO2 tube is connected to the Veress needle and insufflation is started. The Veress intraperitoneal pressure is controlled and it should be below 5mmHg. This is a reliable indicator of intraperitoneal placement. If pressure suddenly increases, it means that the needle has hit something, so it is necessary to pull up the abdominal wall without touching the needle. One will immediately see that intraperitoneal pressure decreases and starts increasing gradually again until the preset pressure is reached.

6. Tests to detect periumbilical adhesions 05'36''

Using a syringe pre-loaded with physiological saline, punctures are made around the umbilicus to perform aspirations. If bubbles are found and resistance is lost, there are no adhesions.

7. Insertion of main trocar through umbilicus 06'31''

The Veress needle is removed and the trocar is placed inside the incision in contact with the fascia at a 60-degree angle. The operator checks that the CO2 valve is opened. The index or middle finger is used to control the trocar’s descent and to gently push down with a rotational movement until the loss of resistance is felt. The trocar is removed, leaving the sleeve in place, and the endoscope is introduced in order to confirm the trocar’s position. The gas is connected, insufflated and the upper abdomen and pelvic cavity are explored.

8. Palmer’s point entry: alternative way 07'20''

Alternative left upper quadrant laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or umbilical hernia. Palmer’s point is located 2cm below the left costal margin in the mid-clavicular line.

9. Palmer’s point incision and needle placement 08'02''

A skin incision is made and the Veress needle is then placed and opened inside the incision, at a 90-degree angle with the fascia.

10. Veress needle insertion 08'26''

The abdominal wall is lifted up below the level of Palmer´s point, keeping the 90-degree angle in relation to the fascia. A gentle push downwards is then performed until two clicks are heard. The first one corresponds to the fascia and the second one to the peritoneum and a loss of resistance is felt, which means the tip of the needle is inside of the abdominal cavity.

11. Safety tests to confirm intra-abdominal placement 08'56''

A safety test should be carried out every time. An empty syringe is placed into the Veress needle and aspiration is carried out. Normally negative intra-abdominal pressure should be found. The abdominal cavity is then insufflated with 20 cc of air and aspiration is again performed. If the needle is correctly placed, negative intra-abdominal pressure should be found again. The CO2 tube is connected to the Veress needle and insufflation is started. The Veress intraperitoneal pressure is controlled and it should be below 5mmHg. This is a reliable indicator of intraperitoneal placement. If pressure suddenly increases, it means that the needle has hit something, so it is necessary to pull up the abdominal wall without touching the needle. One will immediately see that intraperitoneal pressure decreases and starts increasing gradually again until the preset pressure is reached.

12. Tests for detecting periumbilical adhesions 10'07''

A syringe pre-loaded with physiologic saline is used to make punctures and aspirate around the umbilicus. If bubbles are found and resistance is lost, there are no adhesions. In case adhesions are suspected, a 5mm trocar as well as a scope could be inserted at Palmer’s point to explore the abdominal cavity.

13. Main trocar insertion through umbilicus 10'58''

With the Veress needle in place, an incision is made inside the umbilicus, parallel to the abdominal wall, and the trocar is then placed inside the incision in contact with the fascia at a 60-degree angle. The operator checks that the CO2 valve is opened. The index or middle finger is used to control the trocar’s descent and to gently push down with a rotational movement until the loss of resistance is felt. The trocar is removed, leaving the sleeve in place, and the endoscope is introduced in order to confirm the trocar’s position. The gas is connected, insufflated and the upper abdomen and pelvic cavity are explored.

14. Direct entry 12'09''

Direct trocar insertion without prior pneumoperitoneum may be considered as a safe alternative to the Veress needle technique. It is associated with less insufflation-related complications such as gas embolism, and it is a faster technique compared to the Veress needle technique.

15. Umbilical incision and trocar placement 12'15''

A left incision is initiated inside the umbilicus parallel to the abdominal wall and the trocar is then placed inside the incision in contact with the fascia at a 90-degree angle.

16. Main trocar insertion through umbilicus 13'49''

The fascia is impacted with the trocar, the abdominal wall is lifted up below the level of the umbilicus, keeping the 90-degree angle in relation to the fascia. The index or middle finger is used to control the trocar’s descent and to gently push down with a rotational movement until the loss of resistance is felt which means the pyramidal tip of the trocar is inside the abdominal cavity. The trocar is removed, leaving the sleeve in place, and the endoscope is introduced in order to confirm the trocar’s position. The gas is connected, insufflated and the upper abdomen and pelvic cavity are explored.

17. Insertion of accessory trocars 14'55''

The first accessory trocar is inserted at the level of the left anterior iliac spine and again at the same level on the right side. The third suprapubic trocar is inserted a few centimeters above a line between the external trocars.

19. Open entry: Hasson\'s technique 15'44''

In Hasson’s technique, which was described by Hasson in the 1970s, a periumbilical incision is made, here supraumbilically, wide enough to have a good view of the aponeurosis which will be freed and fixed by two stitches, using rather long suture threads, as they will help to fix the trocar. An incision is then made into the aponeurosis and into the peritoneum under visual control. Hasson’s port has a conical-shaped system, which is placed around the cannula. Once the abdominal cavity has been opened, this port is introduced, and its blunt-tip prevents any trauma at the level of the bowel loops. The cone is then fixed, using the suture threads, which are laid on the aponeurosis. This allows for complete airtightness, which prevents gas from leaking out at the cone level. This is a single-use system, but multiple-use systems are also available from Karl Storz™. The abdominal cavity is then insufflated under visual control and the operator can subsequently rule out the presence of trauma. The advantage of this system is that it allows for port mobility within the fixation cone.