SAFE LAPAROSCOPYSAFE LAPAROSCOPY

THE ROLE OF NEEDLE- SCOPETHE ROLE OF NEEDLE- SCOPE

Mamdouh Sabry Mamdouh Sabry

M.D. Ain Shams, Ph.D. FranceM.D. Ain Shams, Ph.D. France

Consultant Ob.&Gyn. Consultant Ob.&Gyn. Mataria Teaching Hosp. & Nasser InstituteMataria Teaching Hosp. & Nasser Institute

CAIRO - EGYPTCAIRO - EGYPT

Complications are unavoidable during Complications are unavoidable during endoscopic surgery, even in experienced endoscopic surgery, even in experienced hands.hands.

The best way to treat complications is to The best way to treat complications is to avoid them as much as possible.avoid them as much as possible.

Blind intra-abdominal placement of Blind intra-abdominal placement of Veress needle in risky patients is Veress needle in risky patients is hazardous as it may enter other space or hazardous as it may enter other space or puncture an organ.puncture an organ.

The risk is increased during introduction The risk is increased during introduction of the main trocar. of the main trocar.

Hiss-phenomenon, negative pressure test Hiss-phenomenon, negative pressure test (drop test).(drop test).

Aspiration test.Aspiration test.

Initial intra-abdominal pressure (Initial intra-abdominal pressure (10mm. 10mm. Hg.) and respiratory changes.Hg.) and respiratory changes.

Palmer test, glass syringe, non resistant Palmer test, glass syringe, non resistant needle.needle.

Safety tests are not safe!!!???Safety tests are not safe!!!???

Pre-operative Security TestsPre-operative Security Tests

The Veress needle

Hiss Hiss testtest

Palmer Palmer testtest

The safety tests have low rate of sensitivity and The safety tests have low rate of sensitivity and

specificity. specificity. (Gomel & Taylor, K. Semm)(Gomel & Taylor, K. Semm)

Safety sheath and shielded trocars don’t reduce Safety sheath and shielded trocars don’t reduce

incidence of traumatic bowel perforation incidence of traumatic bowel perforation (Gomel (Gomel

V., Taylor P. (1995)V., Taylor P. (1995) specially if the bowel is specially if the bowel is

attached to Anterior abdominal wall attached to Anterior abdominal wall (M. Sabry et (M. Sabry et

al (98, 2000) & Lee PI et al (1999)al (98, 2000) & Lee PI et al (1999)

Various techniques have been tried to overcome Various techniques have been tried to overcome

introduction problems and encourage use of introduction problems and encourage use of

laparoscope in conditions which were impossible laparoscope in conditions which were impossible

before. before.

Bowel injury with the Bowel injury with the principal trocar and cannula. principal trocar and cannula. (I) If the bowel has been (I) If the bowel has been transfixed by the cannula, transfixed by the cannula, will not be apparent when the will not be apparent when the laparoscope is introduced.laparoscope is introduced.

(I)

Severe cardio-respiratory disease.Severe cardio-respiratory disease.

Large abdominal and diaphragmatic hernia.Large abdominal and diaphragmatic hernia.

Generalized peritonitis.Generalized peritonitis.

Severe ileus, intestinal obstruction.Severe ileus, intestinal obstruction.

Inexperienced surgeon Inexperienced surgeon (Corfman RS, Diamond (Corfman RS, Diamond

MP, De Cherney A (1993), Gomel, Taylor (1995).MP, De Cherney A (1993), Gomel, Taylor (1995).

Major contraindications to Major contraindications to laparoscopy laparoscopy

Prior abdominal or pelvic ?! Surgery or Prior abdominal or pelvic ?! Surgery or

inflammatory bowel disease.inflammatory bowel disease.

Extremes in body wt.Extremes in body wt.

Intra-uterine pregnancy ?!.Intra-uterine pregnancy ?!.

Large intra abdominal mass.Large intra abdominal mass.

Displaced or enlarged organs Displaced or enlarged organs (Gomel, Taylor (Gomel, Taylor

1995).1995).

Relative contraindicationsRelative contraindications

Peritoneum Fascia

Subcutaneous fat Rectus abdominalSkin

The umbilical area is best for introducing the Veress needle

Rectus abdominal

Peritoneum Fascia

umbilicus

Angle of trocar insertion with operating table in flat (A) and in Trendelenberg position (B).

A B

Orientation of the umbilical trocar in supine position

Loss of orientation with premature Trendelenberg

Alternative abdominal insertion site for insufflation. Alternative abdominal insertion site for insufflation. (1)(1) Infra-umbilical. Infra-umbilical.

(2)(2) Left upper quadrant midclavicular. Left upper quadrant midclavicular. (3)(3) Supra-umbilical. Supra-umbilical. (4)(4) Midline Midline

suprapubic. suprapubic. (5)(5) Left lower quadrant, McBurney’s point. Left lower quadrant, McBurney’s point.

Liver Stomach

Transverse colon

Alternative insertion sites for Veress needle

2

4

Visual controlled perforation with (5mm) Visual controlled perforation with (5mm) optics trocar optics trocar (K. Semm, 1976).(K. Semm, 1976).

Optical access trocar Optical access trocar (L. Mettler, M. Ibrahim et al., (L. Mettler, M. Ibrahim et al., 1997).1997). available in the form of optiview by available in the form of optiview by ethicon and surgiview by US surgical.ethicon and surgiview by US surgical.

Open technique (Hasson Cannula).Open technique (Hasson Cannula).

Endo TIP (Threaded Imaging Port) system Endo TIP (Threaded Imaging Port) system (storz).(storz).

Needle-scope (2-3) mm. storz. Needle-scope (2-3) mm. storz. (M. Sabry et al (M. Sabry et al (98, 2000).(98, 2000).

Visual controlled peritoneal Visual controlled peritoneal perforationperforation

Optical trocar

Optical trocar and handle

Endo TIP system

Open technique is slower, needs fascial Open technique is slower, needs fascial sutures to ensure air tight seal sutures to ensure air tight seal (Hurd W.W, (Hurd W.W,

Nichols D. 1995)Nichols D. 1995) needs special skill. needs special skill.

Optical trocar is a modification of Semm Optical trocar is a modification of Semm technique and better done by Z technique as technique and better done by Z technique as it requires wide opening to decrease power it requires wide opening to decrease power of penetration and it is single use (most of of penetration and it is single use (most of them).them).

L. Mettler, M. Ibrahim et al reported L. Mettler, M. Ibrahim et al reported occasional hernias following optic trocars occasional hernias following optic trocars (1997).(1997).

Needle-scope is the development of the optic Needle-scope is the development of the optic trocar technique of K. Semm.trocar technique of K. Semm.

Its diameter is (1.2-2.9) mm which is Its diameter is (1.2-2.9) mm which is negligible if bowel perforation did happen.negligible if bowel perforation did happen.

It allows inspection and choice of adhesions It allows inspection and choice of adhesions free area and enables introduction of 10 mm. free area and enables introduction of 10 mm. trocar under vision.trocar under vision.

It is very helpful during pregnancy and in It is very helpful during pregnancy and in generalized peritonitis. generalized peritonitis. (O’Sullivan et al., 1996 (O’Sullivan et al., 1996 Nezhat C. et al., 1997 & M.Sabry et al., 1998, 2000) Nezhat C. et al., 1997 & M.Sabry et al., 1998, 2000)

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3 4

Correlation between skin incision, prior surgery, and subsequent adhesion formation

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Incision typeIncision type PfannenstielPfannenstiel Pfannenstiel Pfannenstiel MidlineMidline Midline Midline Midline Midline Midline Midline

Incision numberIncision number MultipleMultiple SingleSingle Multiple Multiple Single Single Multiple Multiple

UmbilicusUmbilicus BelowBelow BelowBelow AboveAbove AboveAbove

NumberNumber 180180 7878 5555 3232 1010 55Di Zerega GSDDi Zerega GSD

Results ActiveActive PreviousPrevious AboveAbove BelowBelow PF. Multi.PF. Multi. PF. Multi. PF. Multi. Prior PIDPrior PID Pregn.Pregn. TotalTotal

periton.periton. periton. periton.

or Obst.or Obst. or Obst. or Obst. Umbli.Umbli. Umbli. Umbli. Gyn.Gyn. Obst.Obst. (FHC)(FHC) 12 wk. 12 wk.

HighHigh 33 33 33 77 33 22 11 00 2222

RiskRisk

LowLow -- 22 22 44 55 44 33 33 2323

RiskRisk

NoNo -- 11 00 22 44 55 33 00 1515

RiskRisk

TotalTotal 33 66 55 1313 1212 1111 77 33 6060

High RiskHigh Risk :: Intestinal or organ injury is unavoidableIntestinal or organ injury is unavoidable

Low RiskLow Risk :: Organ injury avoidable by left upper quadrant entry – open lap.Organ injury avoidable by left upper quadrant entry – open lap.– optic trocar.– optic trocar.

No RiskNo Risk :: Umbilical area is free at entry. Umbilical area is free at entry.

Risk score

1.1. (Generalized) peritonitis:(Generalized) peritonitis: ActiveActive : 3: 3 OldOld : : 22

2.2. Int. obstruction:Int. obstruction: AcuteAcute : 3: 3 OldOld : : 22

3.3. Abd. Or diaphragmatic hermiaAbd. Or diaphragmatic hermia : 3: 3

4.4. Midline incision aboveMidline incision above : 3: 3

5.5. Midline incision belowMidline incision below : 2 : 2 6.6. Pfannestiel recurrent Gyn.Pfannestiel recurrent Gyn. : 2: 2

7.7. Pfannestiel recurrent Obs.Pfannestiel recurrent Obs. : 1: 1

8.8. PID recurrent.PID recurrent. : 2: 2

9.9. Extremes of body wt.Extremes of body wt. : 1 : 1 Score 3 needle scope – open laparoscopy (umbilical or extra umbilical).

Score 2 left upper quadrant or open technique. Score 1 Umbilical entry.

Score 3 needle scope – open laparoscopy (umbilical or extra umbilical).

Score 2 left upper quadrant or open technique. Score 1 Umbilical entry.

Bowel adherence to anterior abdominal Bowel adherence to anterior abdominal wall, peritonitis, pregnancy are no longer wall, peritonitis, pregnancy are no longer contraindications to laparoscopy.contraindications to laparoscopy.

It was difficult to tell which patient with It was difficult to tell which patient with recurrent abdominal operation can do recurrent abdominal operation can do safe laparoscopy, Now it is possible.safe laparoscopy, Now it is possible.

Needle-scope indications are the Needle-scope indications are the contraindications to laparoscopy.contraindications to laparoscopy.

Conclusion

It has to be present in teaching and It has to be present in teaching and

university hospitals and referral centers.university hospitals and referral centers.

We believe that technology, money and we as We believe that technology, money and we as

surgeons will offer our patients the benefits surgeons will offer our patients the benefits

of endoscopic surgery, a field that represents of endoscopic surgery, a field that represents

the surgery of the present and future, away the surgery of the present and future, away

from serious vascular or visceral injuryfrom serious vascular or visceral injury

Conclusion (Cont.)

DO NOT FORGET!!!

• حير و بثورته العالم ابهر المصري الشعب انبلد هي مصر ان و باختياراته العالممنظمة دولة و حكومه اول و المتناقضات .بالتاريخ

• The Egyptians surprised the world by their revolution and confused the world by their choices. Egypt, the country of paradox!!!

THANK YOUTHANK YOU