Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery

No. 193-Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT.

Jain point: A new safe portal for laparoscopic entry in previous surgery cases

INTRODUCTION

The present study was performed to assess the safety and feasibility of a new laparoscopic entry site in cases suspected of adhesions due to previous surgery.

MATERIALS AND METHODS

It is a retrospective study undertaken at a tertiary care referral center for advanced gynecological laparoscopic surgery from January 2011 to December 2014.

RESULTS

In 624 patients with a history of previous abdominal surgeries, the laparoscopic entry site was through a newly devised point. It is a point in the left paraumbilical region at the level of umbilicus, in a straight line drawn vertically upward from a point 2.5 cm medial to anterior superior iliac spine. Intra-abdominal adhesions were found in 487 (78.0%) patients, and umbilical adhesions in 404 (64.7%) patients with past abdominal surgeries.

CONCLUSION

There were no significant entry-related, intra-operative, or postoperative complications with the use of this entry point. It is also suitable as a main working port during the course of surgery.

Access-related complications - an analysis of 6023 consecutive laparoscopic hernia repairs

In order to investigate incidence rates and types of access-related complications that may occur during laparoscopic hernioplasty, we carried out a systematic analysis of our collected results. The aim was to identify risk factors and to develop useful modifications of the surgical technique and the instrumentation used. Since we first introduced laparoscopic hernioplasty in our clinic, we have carried out standardised, prospective documentation of relevant data from all consecutive operations in an electronic database. We performed a systematic analysis of access-related complications and their possible influencing factors, taking into special account the type of instruments used, port-site and prior intra-abdominal operations. Between April 1993 and March 2000, 4857 consecutive patients received a total of 6023 laparoscopic hernia repairs. In 510 patients three-edged, sharp trocars were used and in 4347 patients conical obturators were used to insert the port. The incidence of access-related complications was 0.9% (44/4857) in the total collection (incision hernias 0.5%, bleeding from abdominal-wall vessels 0.2%, bowel injury 0.06%, wound infections 0.06%). Injuries to intra-abdominal or retroperitoneal vessels were not observed. A differentiated analysis of the various trocar types, taking into consideration the number of inserted ports, showed that for incisions outside the linea alba the incidence of bleeding from abdominal-wall vessels was 12 times higher (0.7%, 7/1020 versus 0.06%, 5/8694). The incidence of incision hernias increased significantly (1.2%, 12/1020 versus 0.02%, 2/8694; p = 0.03) when three-edged trocars were used, as opposed to conical obturators. Our results demonstrate that, outside the linea alba, three-edged trocars should no longer be used for portinsertion. The results of our differentiated analysis of laparoscopic hernia repairs, taking into account the type of obturator, the port-site and number of ports inserted, also can be applied to other laparoscopic operations.

Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m2) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.

Laparoscopic entry: a review of techniques, technologies, and complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. 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 CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. 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 to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. 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. (II-B) 12. 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. (I-A) 13. 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. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Isobaric (gasless) laparoscopic uterine myomectomy

The aim of this review has been to assess the usefulness and effectiveness of isobaric (gasless) laparoscopic myomectomy using a subcutaneous abdominal wall lifting system, and to evaluate the advantages and disadvantages of this technique in comparison with the conventional laparoscopic myomectomy using pneumoperitoneum. Laparoscopy using CO2 is more frequently employed for small or medium-sized myomas. Furthermore, multiple myomectomies (>or=3 myomas per patient) are performed rarely. Gasless laparoscopy permits the removal of large intramural myomas overcoming the difficulties associated with laparoscopic myomectomy using pneumoperitoneum. It appears to offer several advantages over conventional laparoscopy, such as elimination of the adverse effects and potential risks associated with CO2 insufflation; use of conventional laparotomy instruments that facilitate several steps of the procedure; reduced operative times and costs. Indeed, this procedure associates the advantages of laparoscopy and minimal access surgery with those of using the laparotomic instruments that are more reliable for uterine closure. The only advantage of the laparoscopy with pneumoperitoneum is the tamponade effect generated by the gas on the small vessels, thus reducing intraoperative bleeding. Laparoscopic myomectomy using CO2 remains the preferred minimally invasive approach for small and medium-sized myomas and when the total number of myomas removed does not exceed 2 or 3. Gasless laparoscopic myomectomy could be mainly indicated for removal of large intramural myomas (>or=8 cm) and/or for multiple myomectomies (>or=3 myomas per patient). Anyhow, further controlled studies are needed to evaluate entirely their respective indications.

Isobaric gasless laparoscopic myomectomy for removal of large uterine leiomyomas

BACKGROUND

This study aimed to evaluate the feasibility and safety of isobaric laparoscopic removal of large myomas (> or = 8 cm) using the Laparotenser, a subcutaneous abdominal wall-lifting system.

METHODS

A series of 63 consecutive patients with at least one large symptomatic subserosal or intramural uterine myoma (> or = 8 cm) underwent an isobaric gasless laparoscopic myomectomy. Conventional laparotomy instruments were used.

RESULTS

The procedure was successfully completed for all 63 consecutive patients. The average size of the dominant myoma was 11 cm. The mean number of myomas removed from each patient was 3.6. The mean blood loss was 143 ml, and the mean operating time was 72 min. No intraoperative complication occurred.

CONCLUSIONS

Gasless laparoscopic myomectomy for the removal of large myomas using the Laparotenser is feasible and safe. It offers several advantages over laparoscopy with pneumoperitoneum.

Optical trocars - types, indications, clinical experiences

Since blind insertion of the Veress needle or the first trocar may cause serious complications, many surgeons prefer to perform a minilaparotomy to safely create the pneumoperitoneum. Optical trocars provide a third option, combining the advantages of the Veress needle with those of the Hasson trocar. We describe the optical trocars provided by two major producers of disposable laparoscopic instruments and report on our experience in using one of those trocars in over 500 operations without a single complication. In our opinion, optical trocars are safe and easy to handle, and offer several advantages over the use of the Veress needle and the minilaparotomy.