Title: Safe Laparoscopic Access: technologies and techniques
1Safe Laparoscopic Access technologies
andtechniques
2Laparoscopic 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.
3Laparoscopic 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
4Laparoscopic complications
- Most complications during laparoscopy occur
during the surgeons first 100 cases. - Soderstrom RM et al.
- Operative Laparoscopy The Masters Technique.
- 1993
5Laparoscopic Abdominal Entry
- Approaches to initial cannula
- Closed insertion without preinsufflation
- Closed insertion with preinsufflation
- Open laparoscopy
6Superficial anatomy of the anterior abdominal wall
7Anatomic landmarks
- Umbilicus at the level of L3 and L4
- Abdominal aorta bifurcation L4 and L5
8Placement of the Veress needle
- Umbilical area
- Lower edge
- Adequate size
- Complete horizontal position
9Placement 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
10Placement of the Veress needle
- Palpating the aorta and sacral promontory
- Grasp the base of umbilicus keep Veress needle
from the abdominal structure
11Placement of the Veress needle
- Using towel clips to elevate the abdominal wall
12Tests 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
13Tests 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
14Tests of peritoneal insertion
15Tests of peritoneal insertion
16Recommended 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)
17Primary 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)
18Primary trocar insertionZ-technique
19Direct trocar insertionwithout preinsufflation
- First described by Dingefelder (1978)
20High 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
21In 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
24Management of abdominal wall access with
probable intraperitoneal adhesion
- Exploratory syringe aspiration test
- Direct Veress needle with optic catheter
- Open laparoscopy
- Alternative access
25Exploratory 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
26Direct Veress needle insertion with optic
catheter ( needle scopy)
- 1.2mm, 1.75mm, 1.98 mm
- Visual control via optics inserted into
- needle
27Open 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
28Open laparoscopy
29Alternative 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 )
30Alternative insertion sites
31Alternative 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
32Alternative access -
the Lee-Huang point
33Storz 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
34Blunt 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
35VISIPORT
- 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
36VERSASTEP 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
37VERSASTEP SYSTEM
38Secondary 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
39Conclusion - 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.
40Conclusion - 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
41Q 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
42Q 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.