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Safe Laparoscopic Access: technologies and techniques

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Title: Safe Laparoscopic Access: technologies and techniques


1
Safe Laparoscopic Access technologies
andtechniques
  • ??? ??
  • ???? ???
  • 96-1-2

2
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.

3
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

4
Laparoscopic complications
  • Most complications during laparoscopy occur
    during the surgeons first 100 cases.
  • Soderstrom RM et al.
  • Operative Laparoscopy The Masters Technique.
  • 1993

5
Laparoscopic Abdominal Entry
  • Approaches to initial cannula
  • Closed insertion without preinsufflation
  • Closed insertion with preinsufflation
  • Open laparoscopy

6
Superficial anatomy of the anterior abdominal wall
7
Anatomic landmarks
  • Umbilicus at the level of L3 and L4
  • Abdominal aorta bifurcation L4 and L5

8
Placement of the Veress needle
  • Umbilical area
  • Lower edge
  • Adequate size
  • Complete horizontal position

9
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

10
Placement of the Veress needle
  • Palpating the aorta and sacral promontory
  • Grasp the base of umbilicus keep Veress needle
    from the abdominal structure

11
Placement of the Veress needle
  • Using towel clips to elevate the abdominal wall

12
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

13
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

14
Tests of peritoneal insertion
15
Tests of peritoneal insertion
16
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)
17
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)

18
Primary trocar insertionZ-technique
19
Direct trocar insertionwithout preinsufflation
  • First described by Dingefelder (1978)

20
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

21
In Morbid Obese Patients
22
(No Transcript)
23

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

24
Management of abdominal wall access with
probable intraperitoneal adhesion
  • Exploratory syringe aspiration test
  • Direct Veress needle with optic catheter
  • Open laparoscopy
  • Alternative access

25
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

26
Direct Veress needle insertion with optic
catheter ( needle scopy)
  • 1.2mm, 1.75mm, 1.98 mm
  • Visual control via optics inserted into
  • needle

27
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

28
Open laparoscopy
29
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 )

30
Alternative insertion sites
31
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

32
Alternative access -
the Lee-Huang point
33
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

34
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

35
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

36
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

37
VERSASTEP SYSTEM
38
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

39
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.

40
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

41
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

42
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.
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