Safe Laparoscopic Entry An Evidence Based View

1. Safe Laparoscopic EntryAn Evidence Based View

4. The Objective of the Topic: to provide the best available evidence on each of the existing laparoscopic entry

5. How Should Surgeons be Trained in Safe Laparoscopic Techniques? Surgeons intending to perform laparoscopic surgery should have: Appropriate training Supervision Experience

6. How Should Surgeons be Trained in Safe Laparoscopic Techniques? Surgeons undertaking laparoscopic surgery should be familiar with the: Equipment Instrumentation Energy sources

7. How Should Surgeons be Trained in Safe Laparoscopic Techniques? Surgeons undertaking laparoscopic surgery should ensure that nursing staff and surgical assistants are appropriately trained for the roles they will undertake during the procedure.

9. Laparoscopic Entry Techniques Gynaecologists have tended to favor the closed or Veress needle entry technique, whereby the abdominal cavity is insufflated with carbon dioxide gas before introduction of the primary trocar & cannula.

11. The Veress Needle Insertion Insertion Sites Insertion technique Safety Tests

12. Under usual circumstances the Veress needle is inserted either in the umbilical area Or In the mid-sagittal plane

14. The Primary Incision for Laparoscopy Under most circumstances, the primary incision for laparoscopy should be vertical from the base of the umbilicus (not in the skin below the umbilicus). Care should be taken not to incise so deeply as to enter the peritoneal cavity.

15. The Veress Needle The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria.

16. Alternative Entry: When? Suspected or known periumbilical adhesions History or presence of umbilical hernia After 3 failed insufflations attempts at the umbilicus

17. What are Alternative Entries?

18. Alternative Entry

22. Left Upper Quadrant (LUQ, Palmer�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.

23. Left Upper Quadrant (LUQ, Palmer�s) Laparoscopic Entry Following pneumoperitoneum, 3-5 mm laparoscopes are introduced at Palmer�s point for inspection, followed by additional trocars, inserted under direct vision, to facilitate the required surgery and/or perform adhesiolysis when indicated.

25. Difficulties in Very Thin & Obese

26. Palmer�s Laparoscopic Entry Palmer�s Laparoscopic Entry may be considered in the obese as well as the very thin patient.

27. Other Sites of Insertion Trans cul-de-sac or Trans uterine Veress CO2 insufflation, may be considered if: 1-The umbilical and LUQ insertions have failed 2- The umbilical and LUQ insertions are not an option

28. Alternative Entry

32. The Veress Needle: Insertion Insertion Sites Insertion Technique Safety Tests

33. The Veress Needle Insertion Technique

34. Insertion Technique In most circumstances the primary incision for laparoscopy should be vertical from the base of the umbilicus (not in the skin below the umbilicus). Care should be taken not to incise so deeply as to enter the peritoneal cavity.

35. Insertion Technique The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria.

36. Insertion Technique The operating table should be horizontal (not in the Trendelenburg tilt) at the start of the procedure. The abdomen should be palpated to check for any masses and for the position of the aorta before insertion of the Veress needle.

37. Insertion Technique The lower abdominal wall should be stabilized in such a way that the Veress needle can be inserted at right angles to the skin and should be pushed in just sufficiently to penetrate the fascia and the peritoneum. Two audible clicks are usually heard as these layers are penetrated.

39. Insertion Technique Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel or vessel into a more complex tear.

40. Insertion Technique The angle of the Veress needle insertion should Vary according to the BMI of the patient from: 45� in non-obese to 90� in very obese

41. Umbilicus & Aortic Bifurcation The position of the umbilicus (CT scan) was caudally to the aortic bifurcation Normal weight (BMI < 25 kg/m2) : 0.4 cm Overweight (BMI 25�30 kg/m2) : 2.4 cm Obese (BMI > 30 kg/m2) : 2.9 cm

46. The Veress Needle Insertion sites Elevation of the anterior abdominal wall Angle of Insertion Safety tests or checks

47. Safety Tests or Checks Double click sound The aspiration test The hanging drop of saline test The �hiss� sound test The syringe test Needle waggling test - to free an attached organ from the tip & confirms intraperitoneal placement

48. Safety Tests

49. Safety Tests

50. What Is The Most Reliable Safety Tests ? The Veress intraperitoneal (VIP) pressure = 10 mm Hg is a reliable indicator of correct intraperitoneal placement of the Veress needle. Therefore, it is appropriate to attach the CO2 source to the Veress needle on entry.

51. Trocar Placement

52. Primary Trocar

53. The most common and dangerous complications are: Vascular injures Bowel injures For prevention adequate pneumoperitoneum is recommended. Primary Trocar

54. What is the Adequate Pneumoperitoneum ? Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO2 volume.

57. Is This high Pressure Entry Safe? Shift from 15 to 30 mmHg ? ? pulmonary compliance by 20% But this effect is not more than the effect of Trendelenburg position at 15 mm Hg. Transient high-pressure 25-30 mmHg causes minor hemodynamic alterations of no clinical significance

60. The High Intraperitoneal laparoscopic Entry The abdominal pressure may be increased immediately prior to insertion of the first trocar with the patient flat. The transient high intraperitoneal laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women.

61. What is the Adequate Pneumoperitoneum ? The distension pressure should be reduced to 12�15 mmHg once the insertion of the trocars is complete. This gives adequate distension for operative laparoscopy and allows the anaesthetist to ventilate the patient safely and effectively.

62. Where should the primary trocar be inserted ? The primary trocar should be inserted in a controlled manner at 90 degrees to the skin, through the incision at the thinnest part of the abdominal wall, in the base of the umbilicus. Insertion should be stopped immediately the trocar is inside the abdominal cavity.

63. One useful technique is to gently twist the trocar with a conical tip, while exerting firm downward pressure. Excessive pressure to overcome skin or fascial resistance can lead to uncontrolled trocar entry, increasing the risk of injury to bowel or other abdominal or retroperitoneal structures. How should the primary trocar be inserted ?

64. How should the primary trocar be inserted ? Once the laparoscope has been introduced through the primary cannula, it should be rotated through 360 degrees to check visually for any adherent bowel. If this is present, it should be closely inspected for any evidence of haemorrhage, damage or retroperitoneal haematoma.

65. How should the primary trocar be inserted? If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site should be visualized from a secondary port site, preferably with a 5mm laparoscope.

66. How should the primary trocar be inserted ? On completion of the procedure, the laparoscope should be used to check that there has not been a through-and-through injury of bowel adherent under the umbilicus by visual control during removal.

72. Disposable Shielded (Safety) Trocars

73. Disposable Shielded (Safety) Trocars

74. FDA database Report (1993-1996): 629 trocar injuries reported : Major vessels injuries : 408 Viscera (mainly bowel): 182 Abdominal wall hematomas 30 Deaths 32 26 (81%):Bowel injuries 6 (19%):Vascular injuries Disposable Shielded Trocars

75. In 1998 and 2000, the Emergency Care Research Institute (ECRI) concluded that although shielded trocars do not totally protect against injuries, they are preferable to unshielded trocars.

76. Disposable Shielded Trocars 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.

77. Trocar Tips Incisional hernia risk is 10 times greater when disposable cutting pyramidal trocar are used instead of reusable conical trocar.

80. Radially Expanding Access System   Several case series and RCT have reported no injury to major vessels and no deaths. Abdominal wall bleeding and veress injury to mesentery have been encountered. It has less postoperative & more patient satisfaction than with the conventional trocar

81. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars Radially Expanding Access System

90. The Visual Entry Cannula System 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.

91. 3-Open Laparoscopic Entry (Hasson Technique)

92. Open Laparoscopic Entry (Hasson Technique 1971)

93. Open Laparoscopic Entry Or Hasson Technique (1971)

94. The suggested benefits are prevention of : 1- Gas embolism 2- Preperitoneal insufflation 3- Visceral 4- Major vascular injury. HASSON (Open)TECHNIQUE

95. Bonjer et al.(G surgery): Significantly Lower Open Versus Closed Laparoscopy

96. 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 or inferior to the other entry techniques currently available.

97. Laparoscopic Entry Techniques Gynaecologists have tended to favor the closed or Veress needle entry technique, before introduction of the primary trocar and cannula. The Royal College of Surgeons recommends the open (Hasson) approach be used in all circumstances

98. Direct Trocar Entry (without prior pneumoperitoneum) The suggested advantages are avoidance of complications of the Veress needle: Failed pneumoperitoneum Preperitoneal insufflation CO2 embolism.

100. Direct Insertion of the Trocar Without Prior Pneumoperitoneum It may be considered as a safe alternative to veress needle technique. It is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the veress needle technique.

101. Very Thin or Obese Women The 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.

105. It arises from the external iliac artery and anastomoses with the superior epigastric artery. It can usually be identified at the junction of the round ligament and the umbilical ligament (obliterated umbilical artery) at the inguinal canal. It lies beneath the rectus muscle and immediately above the peritoneum, coursing cephalad just medial to the lateral edge of the rectus muscle. Generally, the artery does not traverse the rectus muscle toward the midline.