Safe Laparoscopic Access: technologies and

techniques

洪煥程 醫師洪煥程 醫師台北榮總 婦產部台北榮總 婦產部

96-1-296-1-2

Laparoscopic Abdominal Entry

Laparoscope-related complications Laparoscope-related complications were reported with increasing were reported with increasing frequency during growing phase of frequency during growing phase of laparoscopic surgery.laparoscopic surgery.

Entering the abdomen is the most Entering the abdomen is the most dangerous part of the laparoscopic dangerous part of the laparoscopic procedures.procedures.

Laparoscopic complications Complications:Complications:

general-anesthesia-relatedgeneral-anesthesia-related injuries to the vascular system, bladder, and injuries to the vascular system, bladder, and

bowel.bowel. These injuriesThese injuries

indirect injury due to the use of monopolar currentindirect injury due to the use of monopolar current now more commonly ascribed as now more commonly ascribed as direct traumadirect trauma

caused by the insertion of the insufflation needle caused by the insertion of the insufflation needle or the primary or secondary trocarsor the primary or secondary trocars

Injuries occur more frequently as a result of the Injuries occur more frequently as a result of the placement of the placement of the insufflating needleinsufflating needle or or primary primary trocartrocar placement. placement.

Levy BS 1985; Reich H 1995Levy BS 1985; Reich H 1995

Laparoscopic complications

Most complications during laparoscopy Most complications during laparoscopy occur during the surgeon’s first 100 occur during the surgeon’s first 100 cases.cases.

Soderstrom RM et al.Soderstrom RM et al.

Operative Laparoscopy: The Master’s Technique.Operative Laparoscopy: The Master’s Technique.

19931993

Laparoscopic Abdominal Entry

Approaches to initial cannulaApproaches to initial cannula Closed insertion without preinsufflationClosed insertion without preinsufflation Closed insertion with preinsufflation Closed insertion with preinsufflation Open laparoscopy Open laparoscopy

Superficial anatomy of the anterior abdominal wall

Anatomic landmarks

Umbilicus: at the level of L3 and L4Umbilicus: at the level of L3 and L4 Abdominal aorta: bifurcation L4 and L5Abdominal aorta: bifurcation L4 and L5

Placement of the Veress needle Umbilical area

Lower edge

Adequate size

Complete horizontal position

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

Placement of the Veress needle

Palpating the aorta and sacral promontory Grasp the base of umbilicus : keep Veress

needle from the abdominal structure

Placement of the Veress needle Using towel clips to elevate the abdominal Using towel clips to elevate the abdominal

wallwall

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 ( < 5-6 mmHg at 1.0L/min flow ) Loss of liver dullness early in insufflation

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

Tests of peritoneal insertion

Tests of peritoneal insertion

Recommended amount of gas for initial insufflation with a Veress needle

MonaghanMonaghan 2-4 2-4 LL

SuttonSutton About 3 LAbout 3 L

GordonGordon 1-2 1-2 LL

SoderstromSoderstrom Pressure (not specified)Pressure (not specified)

Deprest & BrosensDeprest & Brosens Preset pressure (not specified)Preset pressure (not specified)

BruhatBruhat Not specifiedNot specified

Hulka & ReichHulka & Reich 20-25 20-25 mmHgmmHg

Tompson & RockTompson & Rock Should not exceed 10 mmHgShould not exceed 10 mmHg

TulandiTulandi 2-3 2-3 L (usually)L (usually)

Primary trocar insertion Patient in a Patient in a horizontalhorizontal

positionposition Skin incisionSkin incision should be should be

large enough to prevent large enough to prevent any resistanceany resistance

A stretched middle A stretched middle finger can prevent over-finger can prevent over-insertion (insertion (palming palming techniquetechnique) )

Z-technique ? Z-technique ? (prevention of incision (prevention of incision hernia)hernia)

Primary trocar insertionZ-technique

Direct trocar insertionwithout preinsufflation

First described by Dingefelder (1978)First described by Dingefelder (1978)

High risk conditions for abdominal entry

Strong abdominal musculature Strong abdominal musculature (sportswomen)(sportswomen)

Body weight is obese or very thinBody weight is obese or very thin Large pelvic massLarge pelvic mass PregnancyPregnancy Previous abdominal and pelvic Previous abdominal and pelvic

operationsoperations

In Morbid Obese Patients

AdhesionAdhesion bowel omentumbowel omentum

Pfannenstiel : Pfannenstiel : 13% 87% 13% 87%

Midline below the umbilicus : 17% 83%Midline below the umbilicus : 17% 83%

Midline above the umbilicus : 40% 60%Midline above the umbilicus : 40% 60%

Subjects with all types of incision : Subjects with all types of incision :

Gynecologic (42 %) > Obstetric (22%)Gynecologic (42 %) > Obstetric (22%)Brill AL: Obs Gyn 1995, 85:269-72

The Incidence of Adhesions After Prior Laparotomy ? (N=360)

Management of abdominal wall access with probable intraperitoneal adhesion

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

Exploratory syringe test(Syringe aspiration test)

To ascertain : no bowel/vessels adherent To ascertain : no bowel/vessels adherent under the umbilicus before trocar insertionunder the umbilicus before trocar insertion

After pneumoperitoneum created by Veress After pneumoperitoneum created by Veress needle, a 20-gauge needle inserted under needle, a 20-gauge needle inserted under negative pressure at the four cardinal points negative pressure at the four cardinal points of a 20-mm circle around the umbilicus ---of a 20-mm circle around the umbilicus ---

alternate sites trocar if blood or bowel content alternate sites trocar if blood or bowel content is aspiratedis aspirated

Direct Veress needle insertion with optic catheter ( needle scopy)

1.21.2mm, 1.75mm, 1.98 mmmm, 1.75mm, 1.98 mm Visual control via optics inserted into Visual control via optics inserted into

needleneedle

Open laparoscopy

1971, 1971, Hasson Hasson A horizontal/vertical incision about 2 cmA horizontal/vertical incision about 2 cm Enter peritoneal cavity by incision of Enter peritoneal cavity by incision of

abdominal wall step by stepabdominal wall step by step Apply Hasson trocar-cannula and Apply Hasson trocar-cannula and

purse-string suture at fascial levelpurse-string suture at fascial level

Open laparoscopy

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 )

Alternative insertion sites

Alternative needle insertion sites

Lt periumbilical area : Lt periumbilical area : - midclavicular line - midclavicular line Transvaginal insertion : Transvaginal insertion : - via post cervix fornix, - via post cervix fornix,

trendelenburg trendelenburg positionposition Transabdominal insertion :Transabdominal insertion : - - Pushed uterus up against the Pushed uterus up against the

abdominal, abdominal, then inserted through then inserted through

abdomen and into abdomen and into fundus of the uterusfundus of the uterus

Alternative access - the Lee-Huang point

Storz TERNAMIAN EndoTIP ( Endoscopic Threaded Imaging Port ) Re-usable trocar Re-usable trocar After umbilical incision and Veress After umbilical incision and Veress

insufflation, a 0° laparoscope is mounted in insufflation, a 0° laparoscope is mounted in the cannula. The tip of the cannula is the cannula. The tip of the cannula is inserted into a tiny fascial incision and inserted into a tiny fascial incision and rotated clockwise rotated clockwise

All the abdominal wall layers are well All the abdominal wall layers are well visualizedvisualized

Blunt Trocar is used to safely create a is used to safely create a

Pneumoperitoneum in the scarred Pneumoperitoneum in the scarred abdomenabdomen

fascial incision should be 1 to 1.5 cm in fascial incision should be 1 to 1.5 cm in sizesize

A long suture is placed on each fascial A long suture is placed on each fascial edgesedges

finger dissection a tunnel or an opening finger dissection a tunnel or an opening into the intraabdominal cavity is gently into the intraabdominal cavity is gently createdcreated

The foamgrip anchoring device is set and The foamgrip anchoring device is set and secured with the previously placed secured with the previously placed suturesuture

VISIPORT™

A 1 cm skin incisionA 1 cm skin incision A telescope is inserted into the A telescope is inserted into the

trocar and the path of entry of the trocar and the path of entry of the trocar into intra-abdominal cavity trocar into intra-abdominal cavity is visualizedis visualized

These planes are cut slowly with These planes are cut slowly with the blade of the trocar (at the tip the blade of the trocar (at the tip of the instrument)of the instrument)

Pneumoperitoneum must be Pneumoperitoneum must be created or abdominal wall created or abdominal wall elevation must be performed prior elevation must be performed prior to the insertionto the insertion

VERSASTEP SYSTEM™ an integrated system combining a an integrated system combining a

Nylon stretchable sheath over a Nylon stretchable sheath over a Disposable Veress needleDisposable Veress needle

Once inserted, the sheath is Once inserted, the sheath is dilated by inserting the trocar (with dilated by inserting the trocar (with a dilator in place)a dilator in place)

no cutting entry bladeno cutting entry bladedecreasing trocar site bleed decreasing trocar site bleed and the potential for an intra-and the potential for an intra-abdominal injuryabdominal injury

creates a smaller fascial defect creates a smaller fascial defect which does not need to be closedwhich does not need to be closed

up to 12mmup to 12mm

VERSASTEP SYSTEM™

Secondary trocar insertions

Off the midline, to the left, above the Off the midline, to the left, above the pubic hairline pubic hairline

TransilluminationTransillumination and under endoscopic and under endoscopic direct visiondirect vision helps to identify the vessels. helps to identify the vessels.

and minimizing the risk of injuryand minimizing the risk of injury Deep Inferior epigastric <-- ext. iliacDeep Inferior epigastric <-- ext. iliac Superficial epigastric <-- femoralSuperficial epigastric <-- femoral

Lateral to the rectus abdominis muscleLateral to the rectus abdominis muscle Lateral to the umbilical ligamentsLateral to the umbilical ligaments Lateral to the deep epigastric vesselsLateral to the deep epigastric vessels Aiming toward the uterus (cul-de-sac) Aiming toward the uterus (cul-de-sac)

and away from the iliac vessels and away from the iliac vessels Keeping the forefingers extended on the Keeping the forefingers extended on the

sleeve sleeve

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.

Conclusion - 2

Put patient in a proper Put patient in a proper positionposition

Understand anatomical Understand anatomical relationrelation

Follow the abdominal entry Follow the abdominal entry principlesprinciples

Be aware of high-risk Be aware of high-risk conditionsconditions

Use proper instruments and Use proper instruments and alternative strategies alternative strategies

Q 1

The angle insertion of Veress needleVeress needle ? degree from the surface of skin

( more obese) 1. 30 degree 2. 45 degree 3. 90 degree 4. 0 degree

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.