safe entry and how to avoid complications

Safe Entry and How to avoid Safe Entry and How to avoid complicationscomplications? ?

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Mahmoud ZakherahProf. Obstertris and Gynecology

15-2-2014E-mail: .mszakhera@yahoo com

mailto:[email protected]

IntroductionIntroduction Laparoscopy is a very common

procedure in gynaecology. Access to the abdomen is the one

challenge of laparoscopic surgery.It was noted that complications of

laparoscopic surgery are mostly entry related and independent on complexity of surgery .

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IntroductionIntroduction To minimize entry related injuries,

several techniques, instruments, and approaches have been introduced.

The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel.

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IntroductionIntroduction Other less serious complications

can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation.

Laparoscopic procedures are minimal invasive surgically minimal invasive surgically but not not minimally invasive physiologically.minimally invasive physiologically.

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Laparoscopic EntryLaparoscopic EntryAccess is the Key of Success

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Laparoscopic EntryLaparoscopic EntryAccess is the Key of SuccessAccess is the Key of Success

Entry into the peritoneal cavity is the most dangerous part of the procedureBe careful…be careful…be

careful…The pneumoperitoneum The pneumoperitoneum – a continuing mistake in laparoscopy

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Laparoscopic EntryLaparoscopic Entry

A. Closed access * Blind Insufflated Veress Needle Entry(1932) Non-insufflated Direct Trocar

Entry(1978) * Visual Optical Trocar insertion(1994)

( Layer by layer)

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Laparoscopic EntryLaparoscopic Entry

B- Open access Hasson Technique 1978 Radially Expanding Access System

(1996) Visual Entry Systems Disposable Optical Trocars Endopath Optiview optical Trocar Visiport optical trocars EndoTIP visual cannula

Veress Needle EntryVeress Needle Entry

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Veress Needle EntryVeress Needle Entry Pneumoperitoneum

instillation of gas into the peritoneal cavity

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Veress Needle ModificationsVeress Needle Modifications

Pressure-sensor-equipped Veress needle

Optical Veress needle (minilaparoscopy)

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Sites of Veress Needle EntrySites of Veress Needle Entry

1-Trans-umbilical :Intra-umblical

Sub or supra umbilical (smiling incision(

11-Extraumbilical

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1-Trans-umbilical :

Veress needle insertion Towards uterus (forgives) Away from vessels (do not

forgives) angle 45

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Checking springChecking spring

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1-Trans-umbilical Clean

Incise

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Realign the umbilicus prior to entry to regain“anatomical” positioning

1-Trans-umbilical Insertion

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Like a dart

1-Trans-umbilical

In every case, theumbilicus was locatedcephalad to where thecommon iliac veincrossed the midline

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Normal : BMI < 25 use angle < 45°

Non obese Mean location of the umbilicus was 0.4 cm caudal to the aortic bifurcation

Overweight BMI 25-30 use angle 45°- 90°

Obese:BMI >30 use angle 90°

Obese Mean umbilical location was 2.4 cm caudal to the bifurcation

Incorrect IncorrectCorrect

Midsagittal Plane Insertion

Veress needle safety testsVeress needle safety tests

(Tests for peritoneal entry)The “hiss” sound test Double click sound of the Veress needle Irrigation test (the syringe test.) Aspiration test (Palmer test) Hanging drop of saline test Insufflation of gas test Needle movement test

Veress needle safety Veress needle safety teststests

Irrigation test Aspiration test

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Veress needle safety testsVeress needle safety tests

Hanging drop test HISS TEST

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Number of Veress needle insertions Number of Veress needle insertions attemptsattempts Complication rates were as follows: one attempt, 0.8% to 16.3%; at 2 attempts, 16.31% to 37.5%; 3 attempts, 44.4% to 64%;

More than 3 attempts, 84.6% to 100%.

Complications were extraperitoneal insufflation, omental and bowel injuries, and failed laparoscopy.

11-Extraumbilical1.1. Left upper quadrant (LUQ,) Left upper quadrant (LUQ,)

PalmerPalmer’’s points point Ninth or tenth intercostal Ninth or tenth intercostal

spacespace 1.1. Transuterine Veress CO2 Transuterine Veress CO2

insufflationinsufflation2.2. Trans cul-de-sac CO2 Trans cul-de-sac CO2

insufflation(Transvaginal) insufflation(Transvaginal)

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Palmer’s point just below

9th rib-midclvicular

Palmer’s Technique

3 cm below the left subcostal border in the midclavicular line

LUQ, Palmer’s point

3 cm below the left subcostal border

Elevation Of The Anterior Abdominal Wall

Veress Needle Insertion

Prerequisites:

Emptying of the stomach by nasogastric

suction

No previous splenic or gastric surgery

No significant hepatosplenomegaly

No portal hypertension

No gastropancreatic masses

Left Upper Quadrant (LUQ, Palmer’s) Laparoscopic Entry

Left Upper Quadrant (LUQ, Left Upper Quadrant (LUQ, Palmer’s) Laparoscopic EntryPalmer’s) Laparoscopic Entry

It should be considered in patients with:

Suspected or known periumbilical adhesions

History or presence of umbilical hernia

After three failed insufflation attempts at the umbilicus.

(SOGC Practice Guideline.193, 2007) (L:II-2 G:A)

Trocar Entry

Conventional trocar and cannulaConventional trocar and cannula

VALVES trap-door (trumpet )

flapper valveSIZE 5,9,10mm. PRIMARY SECONDARY

Tips pyramidal or

conical tip

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TROCARS

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Conventional Trocar and Cannula

Trocar EntryTrocar Entry1-Primary trocar

With pneumopeitoneun (conventional)VNEWithout pneumoperitoneum ( DTE)

2-Secondary trocars

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2-Secondary trocars

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Optical access trocarsOptical access trocars

i. Visiport uses a blade that strikes the fascia and peritoneum under laparoscopic guidance.

ii. Optiview uses a conical clear tip that is rotated under laparoscopic vision as it penetrates the fascia and peritoneum

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Trocar EntryTrocar Entry

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Trocar EntryTrocar Entry43

TROCAR INSERTIONTROCAR INSERTION

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Laparoscopic PearlsLaparoscopic Pearls

Primary ports 45 angle of entry Stay midline Keep patient flatIf the same angle of insertion is used in

the Trendelenburg position, the trocar may be directed at the great vessels

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Trocar EntryTrocar Entry

Low pressure entry

≤15mmHgHigh pressure entry (Garry

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High pressure trocar entryHigh pressure trocar entryTemporary higher inflation

pressure (25-30mmHg)The use of transient HIP-Entry does

not adversely affect cardiopulmonary function in healthy women.

↑ separation between viscera and anterior abdominal wall

May therefore reduce risk of injury

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14 mm Hg 20 -30mm Hg

The High Pressure Entry

The tip of the trocar can injure .abdominal contents The tip of the trocar is away from

abdominal contents.

3 kg force

3 kg force

25 mm Hg15 mm Hg

The tip of the trocartouched abdominal contents

> 4 cm maintained. the tip of the trocar never touched abdominal contents.

Phillips et al Gynaecol Endosc 1999;8:369–74.

Trocar insertion requires 4 to 6 kg of force

Tarney et al . Obstet Gynecol 1999;94:83–8.

< 4 cm

The High Pressure Entry

So the pressure of 25-30 mmHg is required



2-Secondary trocars

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Direct Trocar EntryWithout pneumoperitoneum

( DTE)

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Direct Trocar EntryDirect Trocar EntryPneumoperitoneum with Veress

needle insertion has actually three blind steps opposed to one in direct trocar entry.

Several reports pointed out that, direct trocar entry without pneumoperitoneum, is a safe alternative to Veress needle entry (RCOG greentop guideline 2009)

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Technique of direct trocar entry Technique of direct trocar entry (DTE(DTE((

Intra-umbilical skin incision wide enough to accommodate the diameter of a sharp trocar/cannual system.

The anterior abdominal wall adequately elevated by the hand, and the trocar was inserted directly into the abdominal cavity, aiming towards the pelvic hollow

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Technique of direct trocar entry Technique of direct trocar entry (DTE(DTE((

After removal of the sharp trocar, the laparoscope was inserted to confirm the presence of omentum or bowel in the visual field then pneumoperitoneum started

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The advantages of direct trocar The advantages of direct trocar entry areentry areThe avoidance of complications related

to the use of the Veress needle as failed pneumoperitoneum, preperitoneal insufflation, intestinal insufflation, or the more serious CO2 embolism

Faster than any other method of entry.Immediate recognition and rapid

treatment of complications.

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Succesful Direct Trocar EntrySuccesful Direct Trocar Entry

Relaxation: Adequate General anesthésiaSharp Trocar: the sharper = saferAdequate IncisionElevation of the abdominal wall (not

necessary)

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2-Secondary trocars

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How Should Secondary Ports be How Should Secondary Ports be InsertedInserted??

The secondary trocar should be placed in a well-controlled fashion under direct visualization

A suprapubic trocar Lateral lower pelvic ports Transillumination of the abdominal wall will

often identify these superficial vessels and aid in trocar placement. These trocars should be placed under direct visualization

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Secondary ports must be inserted under

direct vision perpendicular to the skin,

while maintaining the

pneumoperitoneum at 20–25 mmHg

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RCOG Guideline No. 49 May 2008


During insertion of secondary ports, the inferior epigastric vessels should be visualised laparoscopically to ensure the entry point is away from the vessels

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Once the tip of the trocar has pierced the peritoneum it should be angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.

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The “Baseball Diamond ConceptThe “Baseball Diamond Concept

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Safety Zones for Anterior Safety Zones for Anterior Abdominal WallAbdominal Wall

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Epigastric vessels are usually located in the area between 4 and 8 cm from the midline. Staying away from this area will determine the safe zone of entry of the anterior abdominal wall.

http://upload.wikimedia.org/wikipedia/commons/6/6f/Gray547.png


Secondary ports must be removed under

direct vision to ensure that any

haemorrhage can be observed and

treated, if present.

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Injury of Epigastric VesselsInjury of Epigastric Vessels

Managementdirect pressure with the operating portfull-thickness abdominal wall suture

ligationFoley catheter balloon tamponade.Exploration of the wound

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Elevation of the anterior Elevation of the anterior abdominal wallabdominal wall

Many surgeons advocate elevating the lower anterior abdominal wall by hand or using towel clips at the time of Veress or primary trocar insertion.

Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B

Open Laparoscopic Entry

))Hasson TechniqueHasson Technique((

Particularly useful in previous abdominal surgery or underlying adhesions

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Complications of laparoscopic Complications of laparoscopic abdominal entryabdominal entry Extraperitoneal insufflation Visceral injury Vascular injury

There are 3 subgroups of patients in whom the creation of a pneumoperitoneum

can be problematic: 1. Obese and thin patients,2. Patients with scars from

previous abdominal surgeries3. patients with failed

insufflations.

Laparoscopic surgery in the obese Laparoscopic surgery in the obese womenwomen

Obesity changes the relationship of the umbilicus to the aortic bifurcation.

In nonobese patients (BMI <25), the umbilicus had a median location 0.4 cm caudal to the bifurcation,.

In overweight (BMI 25 to 30) and obese (BMI >30) patients, the umbilicus had a median location 2.4 and 2.9 cm caudal to the aortic bifurcation, respectively.

Laparoscopic surgery in very thin Laparoscopic surgery in very thin womanwoman

Liable to more complicationsThe Hasson technique or insertion

at Palmer’s point is recommended for the primary entry in women who are very thin and women with morbid obesity

RCOG Guideline No. 49 May 2008 Grade C

AimAim

Safe Laparoscopy

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Safe Entry

RCOG green top guidelinesRCOG green top guidelinesPrimary incision for laparoscopy

should be vertical from the base of the umbilicus (not in the skin below the umbilicus)

The Veress needle should be sharp, with a good and tested spring action

The operating table should be horizontal (not in the Trendelenburg tilt) at the start of the procedure

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RCOG green top guidelinesRCOG green top guidelinesAn intra-abdominal pressure of 20–

25 mmHg should be used for gas insufflation before inserting the primary trocar (HPE).

The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete

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RCOG green top guidelinesRCOG green top guidelines

During insertion of secondary ports, the inferior epigastric vessels should be visualised laparoscopically to ensure the entry point is away from the vessels..

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During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be angled towards the anterior pelvis under careful visual control until the sharp tip has been removed

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Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed and treated, if present.

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Risk of herniationRisk of herniation Hernias at the site of laparoscopic

ports are significantly more common with 12-mm trocars.

Close fascia, therefore, when you’ve used any type of trocar that is 10 mm or greater in diameter.

Chiong et al .. 2010;75(3):574–580.

RecommendationsRecommendations

Guidelines approved by the Executive and Council of the Society of Obstetricians an Gynecologists of Canada 2007.

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Society of Obstetricians an Society of Obstetricians an

Gynecologists of Canada 2007Gynecologists of Canada 2007. . Left upper quadrant (LUQ, Palmer’s)

laparoscopic entry should be considered in patients with suspected or known or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A)

Other sites of insertion, such as transuterine Veress CO2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A)

The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle.

It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to 1 cm in viscera or blood vessels,


Gynecologists of Canada 2007Gynecologists of Canada 2007. .

The Veress intraperitoneal (VIP-pressure 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veres needle;therefore, it is appropriate to attach the CO2 source to the Veress needle on entry. (II-1 A)



The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 in non-obese women to 90 in obese women. (II-2 B)



Elevation of the anterior abdominal

wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B)



The volume of CO2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO 2 volume. (II-1 A)



In the Veress needle method of entry, the

abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A)



The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry.

There is no evidence that the open entry technique is superior to or inferior to the

other entry techniques currently available. (II-2 C)



Society of Obstetricians an Society of Obstetricians an Gynecologists of Canada 2007Gynecologists of Canada 2007 No significant risk differences have

been found for bowel and vascular injuries, when comparing the open-entry to the closed-entry technique.

Evidence level A1 [11]

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20122012

An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury.

Direct insertion of the trocar without prior pneumoperitoneum may bconsidered as a safe alternative to Veress needle technique. (II-2)

Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I)



Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle.

The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.

20122012

Shielded trocars may be used in an

effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B)



The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored.

The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are not-superior to other trocars since they do not avoid visceral and vascular injury. (2 B)



Arm tuckingArm tucking Avoid brachial plexus injury in

laparoscopic surgery by always tucking the arms, instead of placing them on arm boards that can inadvertently be moved beyond horizontal during the surgery.

Shveiky et al .. 2010;17(4):414–420.

Release of gas CompletelyRelease of gas Completely

Evacuate all gas and instruct the anesthesiologist to perform five manual inflations of the lungs before the patient is taken out of Trendelenburg position.

Phelps P, et al .Obstet Gynecol. 2008;111(5):1155–1160.

RecommendationsRecommendations Surgeons intending to perform

laparoscopic surgery should have appropriate training, supervision and experience.

Surgeons undertaking laparoscopic surgery should be familiar with the equipment, instrumentation and energy sources they intend to use.

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اللهم سبحانكوبحمدك

انت ال اله ل ان اشهداليك واتوب استغفرك

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If your only toy is a hammer every problem will look like a

nail

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