Underreporting of Veress Needle Injuries: Comparing Direct Observation and Chart Review Methods

BACKGROUND

Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events.

MATERIALS AND METHODS

Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries.

RESULTS

Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts.

CONCLUSIONS

Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.

[OPEN LAPAROSCOPY--A MODIFIED HASSON TECHNIQUE]

The open technique was first described by Hasson in 1970. This technique consists of creating a small umbilical incision under direct visualization to enter the abdominal cavity followed by the introduction of a blunt trocar. Pneumoperitoneum is then rapidly created. Hasson proposed its potential benefits to be the avoidance of blind insertion of the Veress needle and bladed trocar, prevention of visceral and vascular injuries, preperitoneal insufflation and gas embolism, guaranteed pneumoperitoneum, and a more anatomical repair of the abdominal wall. Since that time, many surgeons have made some modifications to first Hasson technique. Here we described the way we do the open laparoscopy in our hospital and different positive and useful details we put to original Hasson version.

Complications of entry using Direct Trocar and/or Veress Needle compared with modified open approach entry in laparoscopy: six-year experience

PURPOSE

To compare the results obtained from three routine laparoscopic entry techniques, including Direct Trocar (DT), Veress Needle (VN), and Open Approach (OA).

MATERIALS AND METHODS

Safety and efficacy of three main laparoscopic entry techniques were evaluated prospectively in 453 consecutive patients who had undergone laparoscopy either with DT, VN, or modified OA technique in recent six years.

RESULTS

Of 453 patients, 105 (23.2%) were operated on with the DT, 168 (37.1%) with the VN, and 180 (39.7%) with the modified OA technique. Statistical differences were seen among the groups in terms of mean age (P = .003), male-to-female ratio (P < .001), indications for the operation (P < .001), and mean trocar insertion time (P < .001). Three major complications (1 colon perforation and 2 iliac artery injuries) occurred in DT and one (iliac artery injury) in VN group, and modified OA group had no major complication (P = .04). Four major complications required laparotomy. Minor complications were seen in 6 (5.8%), 9 (5.4%), and 17 (9.4%) patients (P = .274) and gas leakage in 4 (3.8%), 16 (9.5%), and 27 (15%) patients (P = .01) in DT, VN, and modified OA groups, respectively.

CONCLUSION

Although DT and VN are rapid and relatively safe, they can be associated with major complications. Therefore, modified OA seems to be safe, feasible, and most acceptable due to less major complications.

Umbilical center insertion method for initial trocar placement in pediatric laparoscopic surgery

BACKGROUND

For laparoscopic surgery in pediatric patients, the initial trocar insertion is usually made employing open laparotomy to avoid injury to the viscera. It is safe but somewhat time-consuming for establishing a pneumoperitoneum, and requires additional sutures for anchoring or preventing air leakage. We devised a new initial trocar insertion technique employing an umbilical center incision to shorten the surgical duration and improve the esthetic appearance.

PATIENTS AND METHODS

Four hundred and thirty-one pediatric patients were indicated for this umbilical center insertion method (UCM) at 2 pediatric surgical departments. Patients suspected of having umbilical lesions (except for umbilical hernia) or extensive bowel adhesions were excluded.

RESULTS

There was no complication associated with UCM. In almost all patients, a pneumoperitoneum was established within 1 minute. The wound was completely within the umbilical ring, and very satisfactory esthetically.

DISCUSSION

We consider UCM to be a safe and easy procedure, and acceptable method of initial trocar insertion for pediatric laparoscopic surgery.

Changes in core temperature during peritoneal insufflation: comparison of two CO2 humidification devices in pigs

BACKGROUND

Various modifications of the physical status of CO2 have been used to reduce hypothermia caused by flow of insufflating gas. This animal study aimed to investigate the effects on core temperature, of insufflation with CO2 using two different humidification devices: unheated, humidified CO2 using the Modified-Aeroneb system (Nektar, San Carlos, CA) and warmed, humidified CO2 using the HME-Booster (Medisize, Hillegom, The Netherlands).

METHODS

We undertook a prospective four-session study on a homogeneous group of four pigs. After general anesthesia, all animals were treated successively with the following protocols in a randomized order at 8-d intervals: Control (no pneumoperitoneum), Standard (unheated, unhumidified CO2), Modified-Aeroneb (unheated, humidified CO2 by cold nebulization), HME-Booster (heated, humidified CO2). The core temperature of the animals was recorded every 10 min.

RESULTS

The temperature decrease is significantly influenced by time (P=0.0001; ANOVA), by the insufflation method (P=0.01), and by the interaction between time and the insufflation method (P=0.0001). The method of contrasts showed the following results:--The temperature decrease in the Standard group and HME-Booster group became greater than in the Control group after 40 min (P=0.02)--The temperature decrease in the Modified-Aeroneb group became greater than in the Control group after 100 min (P=0.04)--The temperature decrease in the Modified-Aeroneb group was less than in the HME-Booster group after 40 min (P=0.04) and less than in the Standard group after 60 min (P=0.01)--The temperature decrease in the Standard group was greater than in the HME-Booster group after 160 min (P=0.005).

CONCLUSIONS

Compared with the HME-Booster system, the Modified-Aeroneb is at least as effective in limiting the drop in core temperature during laparoscopic insufflation.

Direct trocar versus veress needle entry for laparoscopy: a randomized clinical trial

AIMS

To compare direct trocar (DT) to Veress needle (VN) entry for the creation of pneumoperitoneum during laparoscopy with regard to the duration of the procedure, volume of gas used, ease of performance, and frequency of complications.

DESIGN

A randomized clinical trial.

SUBJECTS AND METHODS

One thousand patients scheduled to undergo diagnostic laparoscopy were recruited for the study. They were randomly allocated to either DT entry (group A, n = 500) or VN (group B, n = 500) for pneumoperitoneum. The laparoscopic procedures were performed by the same surgeon.

OUTCOMES

The duration of the procedure, volume of gas consumption, ease of performance and frequency of complications were analyzed.

RESULTS

Patients in the 2 groups had similar demographic characteristics. The mean duration of the procedure was significantly shorter in group A (2.2 +/- 0.7 min, 95% CI 2.14-2.26) than in group B (8.2 +/- 1.4 min, 95% CI 8.08-8.32; p < 0.0001). The mean gas consumption was significantly less in group A (2.6 +/- 0.9 liters, 95% CI 2.52-2.68) than in group B (8.4 +/- 2.6 liters, 95% CI 8.17-8.63; p < 0.0001). No major complications in both groups were encountered. Minor complications were significantly less in group A (0.4%, 95% CI 0.77-3.23) than in group B (14%, 95% CI 10.96-17.04; p < 0.0001).

CONCLUSIONS

DT entry is a safe alternative to the VN entry technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost and instrumentation and rapid creation of pneumoperitoneum.

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.

[Pneumoperitoneum in laparoscopic surgery--techniques of achievement and complications]

The development of endoscopic techniques enables their application in numerous and increasingly extensive surgical procedures. Most complications related to laparoscopy are connected with the first blind entry into the peritoneum. The following paper presents the most frequently used methods of achieving pneumoperitoneum and related complications. Further research is essential to define the optimal method for achieving pneumoperitoneum and reducing the risk of complications.

Prospective study comparing the bladeless optical access trocar versus Hasson open trocar for the establishment of pneumoperitoneum in laparoscopic renal procedures

INTRODUCTION

To present a single centre prospective randomized study on the use of the bladeless Optiview system (Ethicon Endosurgery, Cincinnati, OH) to create the pneumoperitoneum in laparoscopic renal procedures reporting the results with regards safety, efficacy and complications and comparing it with the Hasson open technique.

PATIENTS AND METHODS

Sixty patients were randomly recruited, 27 to the open and 33 to the bladeless group at the Bristol Urological Institute, UK. Time to insertion, time to closure and any intraoperative and postoperative complication related to trocar insertion was recorded.

RESULTS

All procedures were performed for renal pathology. BMI values were similar in both groups. The mean time to insertion of the 12 mm Hasson and Bladeless trocars were 443 and 125 seconds, respectively (p < 0.0001). The incision in the bladeless group was only closed when the defect exceeded 12 mm (38%) or extended for specimen removal (23%), resulting in a mean time to closure of 203 seconds. In the Hasson group, entry into the abdominal cavity could not be confirmed in two patients (7.4%) due to multiple adhesions. In the Bladeless group, there was one failed placement (3%) requiring conversion to the Hasson technique and two injuries to intraabdominal structures (peritoneal minor bruising, liver injury requiring conversion to open procedure, 6%), There was one incidence of gas leakage (3%). There were no reports of port site herniation at a mean follow up of 9 months.

CONCLUSION

Direct placement of a bladeless trocar under direct vision in a desufflated abdomen can reduce port placement time when compared to the Hasson technique. The benefits are maximised by using the bladeless trocar for procedures not requiring intact specimen removal. However, despite visualisation of tissue layers, this port cannot prevent serious intra abdominal injuries that can occur in a higher percentage of cases in comparison to the Hasson technique.

[Surgical treatment of ureteropyelic junction stenosis using robotic-assisted laparoscopy]

Since the introduction of mini-invasive surgery approximately thirty years ago, Laparoscopic surgery has significantly evolved both in terms of its extended field of application and of the tools used which were diversified and improved. More recently, the development of robotic-assisted laparoscopy has brought, among other improvements, three-dimensional vision, dexterity, and a comfortable working position, which have reduced the surgeon's fatigability, the difficulties related to the operations and the learning curves of standard laparoscopy. Urology, which makes slightly less use of standard laparoscopy than general or gynaecological surgery, largely benefits from robotics concerning the precision of movements, and has much increased the operating indications of laparoscopy, including the treatment of pyeloureteral junction, kidney tumourectomy, living donor nephrectomy and radical prostactectomy. This chapter describes the operative technique used for the treatment of the ureteropyelic junction stenosis by robotic-assisted laparoscopy, as carried out in Nancy University Hospital with the da Vinci robot (Intuitive Surgical).

Open Veress Assisted technique. Results in 2700 cases

AIM

The risks of specific complications of the laparoscopic technique, caused by pneumoperitoneum and by insertion of the first trocar, although rare, are frequently reported in literature.

METHODS

A retrospective study of the complications we had in the period from October 1998 to December 2006 was made on 2700 patients who did not need any trocars in the umbilicus or with scars due to previous surgery, who were treated with a particular technique of pneumoperitoneum induction and the insertion of the first trocar, named ''Open Veress Assisted'' (OVA).

RESULTS

We had two visceral complications (0,07%) (ileal perforations).

CONCLUSION

Although no surgical technique is without risks, we believe that the use of our technique is safer than a blind insertion of the first trocar, especially among the patients with scars due to previous surgery.

Measurements of intraperitoneal pressure and the development of a feedback control valve for regulating pressure during flexible transgastric surgery (NOTES)

BACKGROUND

High intraabdominal pressures during laparoscopy (greater than 15 mm Hg) are dangerous. Pressures developed during translumenal endosurgery when using flexible endoscopes without feed-back regulation are unknown.

OBJECTIVE

To measure and control intraabdominal pressures during transgastric endosurgery.

DESIGN

In a blinded study, intraabdominal pressures during unregulated transgastric cholecystectomy and tubal ligation were measured by using Veress needles in 5 pigs (group 1). The accessory channel valve of a double-channel gastroscope was modified to allow measurement and control of intraabdominal pressures with a laparoscopic insufflator. This was tested prospectively in another blinded study in 5 pigs (group 2) that underwent identical procedures to those in group 1, with independent Veress needle pressure measurements.

SETTING

This ethically approved study was performed in an experimental surgical operating theater.

INTERVENTIONS

Transgastric cholecystectomy (n=4) and tubal resection (n=6).

MAIN OUTCOME MEASURES

Intraabdominal pressure measurements during transgastric endosurgery, with and without feed-back control.

RESULTS

The mean (standard deviation) number of pressure measurements per procedure greater than 20 mm Hg was 11+/-1.41 in group 1 and 0+/-0 in group 2 (P<.05). Most episodes of high pressure were undetected by the endoscopist, who was blinded to the pressure measurements.

CONCLUSIONS

Unacceptably high intraabdominal pressures were common during translumenal endosurgical procedures. Feedback pressure regulation through a modified valve prevented overinflation.

Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery

BACKGROUND

The peroral transgastric endoscopic approach for intraabdominal procedures appears to be feasible, although multiple aspects of this approach remain unclear. This study aimed to measure intraperitoneal pressure in a porcine model during the peroral transgastric endoscopic approach, comparing an endoscopic on-demand insufflator/light source with a standard autoregulated laparoscopic insufflator.

METHODS

All experiments were performed with 50-kg female pigs under general anesthesia. A standard upper endoscope was advanced perorally through a gastric wall incision into the peritoneal cavity. The peritoneal cavity was insufflated with operating room air from an endoscopic light source/insufflator. Intraperitoneal pressure was measured by three routes: (1) through the endoscope biopsy channel, (2) through a 5-mm transabdominal laparoscopic port, and (3) through a 16-gauge Veress needle inserted into the peritoneal cavity through the anterior abdominal wall. The source of insufflation alternated between on-demand manual insufflation through the endoscopic light source/insufflator using room air and a standard autoregulated laparoscopic insufflator using carbon dioxide (CO(2)).

RESULTS

Six acute experiments were performed. Intraperitoneal pressure measurements showed good correlation regardless of measurement route and were independent of the type of insufflation gas, whether room air or CO(2). On-demand insufflation with the endoscopic light source/insufflator resulted in a wide variation in pressures (range, 4-32 mmHg; mean, 16.0 +/- 11.7). Intraabdominal pressures using a standard autoregulated laparoscopic insufflator demonstrated minimal fluctuation (range, 8-15 mmHg; mean, 11.0 +/- 2.2 mmHg) around a predetermined value.

CONCLUSION

Use of an on-demand unregulated endoscopic light source/insufflator for translumenal surgery can cause large variation in intraperitoneal pressures and intraabdominal hypertension, leading to the risk of hemodynamic and respiratory compromise. Safety may favor well-controlled intraabdominal pressures achieved with a standard autoregulated laparoscopic insufflator.

Carbon dioxide embolism during laparoscopic cholecystectomy due to a patent paraumbilical vein

Carbon dioxide embolism is a rare but potentially fatal complication of laparoscopic surgery. The most common cause is inadvertent injection of carbon dioxide into a large vein or solid organ during initial peritoneal insufflation. We describe a case of carbon dioxide embolism in a 13-year-old boy during an elective laparoscopic cholecystectomy, caused by injection of carbon dioxide into a large paraumbilical vein. The clinical manifestations of carbon dioxide embolism were hypotension, bradycardia, and an abrupt drop in end-tidal CO2. He subsequently did well and had no sequelae. Carbon dioxide embolism is a recognized complication of laparoscopic surgery, although the risk to the patient may be minimized by the surgical team's awareness of the problem, continuous intraoperative monitoring of end-tidal CO2, and using an open technique for initial access to the peritoneum.

[The hand-assisted laparoscopic resections of colon's left parts]

Authors have an experience of 88 hand-assisted laparoscopic procedures. Results of 32 hand-assisted resections of colon's left parts are analyzed. The special original sealing device was used for making of pneumoperitoneum during laparoscopic procedures. The study group consisted of 19 female and 13 male patients. Mean age was 60.0 +/- 9.8 years (42-76 ys). Overweight was seen at 23 (72%) patients, 12 of them had obesity of I-III stage. Previous abdominal operations have been performed at 11 (34.4%) patients. Mean time of surgery was 181 +/- 53 min, operative bleeding--92 +/- 65 ml, no intraoperative complications occurred. Length of minilaparotomy was 7.3 +/- 0.8 cm. Poltoperative complications were seen at 4 (12.5%) cases, there were no lethal outcomes. Mean hospital stay was 9.8 +/- 3.5 bed-days.

Evaluation of tests performed to confirm the position of the Veress needle for creation of pneumoperitoneum in selected patients: a prospective clinical trial

PURPOSE: To evaluate tests performed to confirm the position of the Veress needle inserted into the left hypochondrium for creation of pneumoperitonium. METHODS: One hundred patients were submitted to laparoscopic procedure with left hypochondrium puncturing. Needle positioning tests were evaluated. The aspiration test was considered positive when organic material was aspirated; the injection test was considered positive when no increased resistance to liquid injection was observed; the recovery test was considered positive when the liquid injected was not recovered; the saline drop test was considered positive when drops of saline in the syringe disappeared quickly; the initial intraperitoneal pressure test was considered positive when pressure levels were £ 8 mmHg. A positive aspiration test indicated iatrogenic injury, whereas a positive result in any of the other tests indicated that the tip of the needle was correctly positioned in the peritoneal cavity. Sensitivity (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) of the tests were calculated by correlating results considered true positives (a), false positives (b), false negatives (c) and true negatives (d), according to the formulas: SE = [a/(a + c)] x 100; SP = [d/(b + d)] x 100; PPV = [a/(a + b)] x 100; NPV = [d(c + d)] x 100. RESULTS: With regard to the aspiration test, SE and PPV were not applicable, SP was 100% and NPV was 100%. With regard to the injection test, SE was 0%, SP was 100%, PPV was inexistent and NPV was 90%. Both recovery and saline drop tests yielded the following results: SE was 50%, SP was 100%, PPV was 100% and NPV was 94.7%. The initial intraperitoneal pressure test yielded the following results: SE, SP, PPV and NPV were 100%. CONCLUSIONS: When inserting the Veress needle into the left hypochondrium, a negative aspiration test guarantees the absence of iatrogenic injury; the injection test is not reliable to determine incorrect needle positioning, but it accurately detects correct needle positioning; recovery and saline drop tests are not reliable to determine correct needle positioning, but they accurately detect incorrect needle positioning; the initial intraperitoneal pressure test is reliable to determine both correct and incorrect needle positioning, and proved to be the most reliable of the tests analyzed.

Laparoscopic intragastric surgery using GelPort

In laparoscopic intragastric surgery for early gastric cancer and submucosal tumors, three trocars are routinely inserted in the gastric lumen. We placed a GelPort hand assist device through a 5-cm transverse incision in the upper abdomen, and inserted the trocars into the gastric lumen through the gel seal cap, snapping the gel seal cap on and off during the operation. This makes it possible to use an open technique in which trocars are inserted into the gastric lumen, and to close the trocar sites in the gastric wall. We believe that the technique described here is easier and saves time compared with inserting trocars and closing trocar sites laparoscopically.

Veress needle insertion in the left hypochondrium in creation of the pneumoperitoneum

PURPOSE

To test the efficacy of the puncture in the left hypochondrium as an alternative method.

METHODS

Sixty-two patients randomly distributed into two groups were studied: Group LH, puncture in the left hypochondrium (n=30), and Group ML, puncture in the abdominal midline (n=32). The following were assessed: needle positioning tests, number of failed attempts at needle insertion, and time needed for creation of pneumoperitoneum. Gas flow, volume and intraperitoneal pressure were recorded at every 20 seconds, until a 12 mmHg pressure was reached inside the peritoneal cavity.

RESULTS

A similar number of positive results for the needle positioning tests were observed in both groups. Two failed attempts to reach the peritoneal cavity were observed in Group ML and one in Group LH. The time necessary for the creation of pneumoperitoneum was on average 3 minutes and 46 seconds for Group LH, and 4 minutes and 2 seconds for Group ML. Average gas flow, volume and pressure were equivalent for both groups.

CONCLUSION

Puncture in the left hypochondrium was as effective as puncture in the abdominal midline for the creation of pneumoperitoneum.

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass

BACKGROUND

In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass.

METHODS

The data on a single surgeon's experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients.

RESULTS

Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 +/- 1.2 s.

CONCLUSIONS

This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.

Costs and benefits of laparoscopic cholecystectomy: abdominal wall lifting vs. pneumoperitoneum procedure

BACKGROUND/AIMS

Gasless laparoscopic surgery using the abdominal wall lifting (AWL) method was first developed in Japan and has been used in various surgical fields. The AWL method allows the use of conventional reusable surgical instruments. The purpose of this study was to compare the cost-effectiveness of laparoscopic cholecystectomy (LSC) using the AWL method in relation to that using pneumoperitoneum (P) method.

METHODOLOGY

Retrospective analysis of 431 LSC procedures between 1991 and 2004 was performed. The two surgical groups consisted of consecutively operated patients with a diagnosis of cholecystolithiasis or gallbladder polyps. One group consisted of 224 LSC procedures performed using the P method from 1992 to 1998 and the other group comprised 207 LSC performed using the AWL method from 1998 to 2004. All instruments used in the P method were disposable, whereas trocars, scissors, dissectors, graspers and L-hook electrodes (excluding clips) used in the AWL method were reusable. Hospital expenses, length of hospital admission and complication rates were analyzed.

RESULTS

Mean hospital cost per case for LSC using the AWL method (dollars 6743) was 7% less expensive than that using the P method (dolars 7215). Costs of operative equipment contributed to the difference (mean dollars 912 per case) in total cost. Conversion to open cholecystectomy occurred in 6 cases (2.9%) using the AWL method and 7 cases (3.1%) using the P method. There were no significant differences in length of hospital admission or complication rates between the two groups.

CONCLUSIONS

LSC using AWL method was less expensive than that using P method. This is mainly due to the use of reusable instruments in the AWL method. If LSC is performed using the AWL method instead of using disposable equipment, considerable savings can be achieved without compromising patient safety.

Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women

STUDY OBJECTIVES

Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University affiliated teaching hospital.

PATIENTS

We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.

INTERVENTION

Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.

CONCLUSION

A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

Evaluation of the positioning of the tip of the Veress needle during creation of closed pneumoperitoneum in pigs

PURPOSE: Erroneous punctures and insufflations are frequent with the use of the Veress needle. Mistaken injections of gas in the preperitoneal space are not rare. The purpose of this research is to evaluate the correct positioning of the tip of the needle during creation of pneumoperitoneum. METHODS: The needle was inserted into the peritoneal cavity. Tests to assess the positioning of the needle tip were carried out. Pressure, flow rate and volume were periodically recorded and the needle was removed, being immediately reinserted into the right hypochondrium and placed in the preperitoneal space. RESULTS: The liquid flow test was always positive in the peritoneal cavity. No resistance to saline injection into the peritoneal cavity was observed, but increased resistance to saline injection into the preperitoneal space was observed in 45.5% of the cases. Some saline was recovered in 63.5% of the cases in the peritoneal cavity, and in 54.5% in the preperitoneal space. Saline drop test was positive in 66.6% of the cases in the peritoneal cavity and in 45.5% in the preperitoneal space. In the peritoneal cavity, initial pressure lower than 5 mm Hg was observed, and this pressure gradually increased during 123 seconds until reaching 15 mm Hg. In the preperitoneal space, initial pressure was 15 mm Hg. CONCLUSIONS: Aspiration, liquid flow and saline drop tests are important, whereas recovery test is inconclusive. Initial pressure of approximately 5 mm Hg indicates that the tip of the needle is in the peritoneal cavity. The peritoneal cavity should hold ten times as much volume of gas as the preperitoneal space. The increase in pressure and volume in the peritoneal cavity can be predicted by statistics.

Safe Veress needle insertion

BACKGROUND/PURPOSE

For laparoscopic surgery, the creation of pneumoperitoneum still remains a must. The insertion of a Veress needle or a trocar is never perfectly safe, and almost every kind of intraabdominal organ injury due to these insertions has been reported worldwide. Here, we describe a safe technique for creating pneumoperitoneum.

METHODS

For the creation of pneumoperitoneum, under direct vision, the linea alba was elevated with two towel clips and then the Veress needle was inserted. We reviewed 368 patients operated on with this technique for complication rates. Ultrasound images were obtained before and during abdominal-wall lifting in 10 patients.

RESULTS

There were no injuries due to the insertion of the Veress needle or trocars. In 90% of the patients, pneumoperitoneum was created successfully on the first attempt. Ultrasound examination demonstrated a mean extra safe area of 11.8 mm during abdominal-wall lifting with this technique.

CONCLUSIONS

Elevating the linea alba during Veress-needle insertion is safe.

A versatile dual-channel carbon dioxide (CO2) insufflator for various CO2)applications. The prototype

BACKGROUND

Carbon dioxide (CO2), with its rapid absorptive nature, has been proven superior to atmospheric air as an insufflating agent in various clinical settings. However, CO2 insufflation has not gained wide clinical acceptance, mainly because there has been no suitable feeding system. The authors therefore have developed a versatile "dual-channel" CO2 insufflator that facilitates wider use of CO2. The objectives of this study were to introduce the authors' prototype insufflator, to evaluate its safety and performance, and to validate CO2 application using the prototype.

METHODS

The prototype insufflator provides one CO2 inlet connected to a regular CO2 gas cylinder and two CO2 outlets positioned on the front and back of the device, respectively. The CO2 gas fed from the cylinder is pressure-regulated and divided into two independent conduits inside the device. The front outlet feeds CO2 gas for pneumoperitoneum at an electronically controlled pressure and flow rate. The back channel supplies CO2 gas at a fixed flow rate, allowing manual control of insufflation for various purposes. The device was evaluated with canine models.

RESULTS

The prototype was safe and performed well. The CO2 application (colonoscopy in this series) using the back channel was feasible while intact CO2 pneumoperitoneum was simultaneously maintained via the front channel. There were no device malfunctions. The serial abdominal x-rays indicated that intraluminal CO2 insufflation such as that used for CO2 colonoscopy caused less residual intestinal gas than conventional air insufflation.

CONCLUSIONS

The dual-channel CO2 insufflator enabled two different modes of CO2 insufflation at the same time from a single CO2 cylinder. The authors are now improving the prototype to allow safer and wider usage of CO2 in the operating room.

The Safety and Efficacy of Direct Trocar Insertion With Elevation of the Rectus Sheath Instead of the Skin for Pneumoperitoneum

Abdominal access in endoscopic surgery carries a finite risk of visceral injury. Bleeding, subcutaneous emphysema, gastrointestinal tract perforation, minor and major vascular injury, and intraperitoneal adhesions are the potential complications associated with abdominal access and creation of pneumoperitoneum. There are 4 basic techniques used to create pneumoperitoneum: blind Veress needle, direct trocar insertion, optical trocar insertion, and open laparoscopy. Veress needle and direct trocar insertion are blind techniques, and their use can result in severe visceral and vascular injuries. To prevent visceral and vascular injuries caused by the technique used for the creation of pneumoperitoneum, laparoscopic surgeons and gynecologists look for safe and effective laparoscopic access techniques. Direct trocar insertion without previous pneumoperitoneum was reported to be a safe alternative to Veress needle insertion. We carried out this study to compare the ease of use, safety, and efficacy of direct trocar insertion with elevation of the rectus sheath and blind insertion of the Veress needle in laparoscopic surgery. In 578 laparoscopic procedures, the patients were assigned to one of the following groups: blind insertion of the Veress needle (group 1, n = 301) and direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277). Total complication rates were 15.7% (n = 33) and 3.3% (n = 4) in groups 1 and 2, respectively (P < 0.05). Direct trocar insertion with elevation of the rectus sheath using 2 towel clips is an easy, safe, and effective technique.

An evaluation of four tests used to ascertain Veres needle placement at closed laparoscopy

STUDY OBJECTIVE

To determine the reliability of four commonly used tests to confirm the placement of the Veres needle during closed laparoscopy and their ability to determine other complications of entry.

DESIGN

A prospective observational study (Canadian Task Force classification II-2).

SETTING

A university-affiliated teaching hospital in Sydney, Australia.

PATIENTS

Three hundred forty-five women undergoing closed laparoscopy using Veres needle peritoneal insufflation.

INTERVENTIONS

The double click test, the hanging drop test, the aspiration test, and the initial five pressures at the time of insufflation following Veres needle placement were assessed for their sensitivity, specificity, and positive and negative predictive values for correct intraperitoneal placement of the needle and the presence or absence of any complication such as preperitoneal insufflation, omental emphysema, or visceral injury.

MEASUREMENTS AND MAIN RESULTS

Complications occurred in 65 (18.8%) of 345 women, with preperitoneal insufflation in 19 (5.5%) of the 345, a superficial gastric injury in 1 (0.3%), and omental emphysema in 45 (13%). There was poor sensitivity and positive predictive values for preinsufflation tests. The first five pressures after commencement of insufflation were a sensitive predictor (79%) of complications, particularly preperitoneal insufflation (100% sensitivity for this complication). When two or more passes of the Veres were required, there was a significantly greater chance of preperitoneal insufflation (chi2 = 20.5, p <.0001). Preperitoneal insufflation was not reported when the first five successive insufflation pressures were less than 10 mm Hg.

CONCLUSIONS

The double click, aspiration, and hanging drop tests provide very little useful information on the placement of the Veres needle at the time of closed laparoscopy. The initial gas pressures provide considerable information on the placement of the Veres needle, in particular the likelihood of preperitoneal insufflation. We conclude that the initial gas pressure is the only valuable measure to reflect correct intraperitoneal Veres needle placement.

The role of optical access trocars in laparoscopic surgery

A literature review between 2000 and 2005 has been conducted for laparoscopic access techniques. The blind insertion of a Veress needle or first trocar to create the pneumoperitoneum has been shown to cause vascular and visceral injuries. To reduce the risk of peritoneal entry, many surgeons prefer an open-access technique, like a Hasson trocar. Other trocars that can be used for laparoscopic entry are direct trocars and radially expanding trocars. No specific technique has been shown to be superior in preventing vascular and visceral complications. Optical trocars combine the advantages of the different entry techniques. This chapter describes the different entry techniques, indications, and clinical experiences of the optical trocars. An optical trocar provides a safe and feasible primary insertion method for laparoscopy in patients prone to access injuries.

Beneficial Effects of Humidified, Warmed Carbon Dioxide Insufflation during Laparoscopic Bariatric Surgery: a Randomized Clinical Trial

BACKGROUND

Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes.

METHODS

We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35 degrees C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented.

RESULTS

Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean+/-SD) in OR time (76+/-16 min vs 101+/-34 min, P=0.02), total hospital length of stay (3.2+/-.4 days vs 4.0+/-.9 days, P=0.01) and end-of-case core temperature (36.2+/-.5 degrees C vs 35.7+/-.6 degrees C, P=0.02) in group 2 compared with group 1.

CONCLUSION

The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.

Double-blind, prospective, randomized study of warmed, humidified carbon dioxide insufflation vs standard carbon dioxide for patients undergoing laparoscopic cholecystectomy

HYPOTHESIS

Patients undergoing warmed, humidified carbon dioxide (CO2) insufflation for laparoscopic cholecystectomy will (1) maintain a warmer intraoperative core temperature, (2) have their surgeon experience less fogging of the camera lens, and (3) have less postoperative pain than patients undergoing laparoscopic cholecystectomy with standard CO2 insufflation.

DESIGN

A double-blind, prospective, randomized study comparing patients undergoing laparoscopic cholecystectomy with standard CO2 insufflation vs those receiving warmed, humidified CO2 (Insuflow Filter Heater Hydrator; Lexion Medical, St Paul, Minn) was performed. Main variables included patient core temperature, postoperative pain, analgesic requirements, and camera lens fogging.

RESULTS

One hundred one blinded patients (69 women, 32 men) undergoing laparoscopic cholecystectomy were randomized into 2 groups-52 receiving standard CO2 insufflation (group A) and 49 receiving warmed, humidified CO2 (group B). Mean patient intraoperative core temperature change (group A decreased by 0.03 degrees C, group B increased by 0.29 degrees C, P =.01) and mean abdominal pain (Likert scale, 0-10) at 14 days postoperatively (group A, 1.0; group B, 0.3; P =.02) were different. Other variables (camera lens fogging, early postoperative pain, narcotic requirements, recovery room stay, and return to normal activities) between groups were similar.

CONCLUSION

While patients undergoing laparoscopic cholecystectomy with warmed, humidified CO2 had several advantages that were statistically significant, no major clinically relevant differences between groups A and B were evident.

[Use of the Hasson technique for creating pneumoperitoneum in laparoscopic surgery]

OBJECTIVE

The aim of this study was to estimate safety and efficacy of Hasson technique in laparoscopic surgery.

MATERIAL AND METHOD

In those patients where adhesions are suspected pneumoperitoneum was achieved by open Hasson technique. The time of this procedure, changes of hemoglobin concentration, duration of hospitalization and postoperative pain was compared with those cases where pneumoperitoneum was performed by blind insertion of the Veress needle.

RESULTS AND CONCLUSIONS

Hasson technique is more time consuming procedure but its safety and efficacy is significantly higher in those patients where adhesions are suspected.

Improving the adverse changes in cardiac autonomic nervous control during laparoscopic surgery, using an intermittent sequential pneumatic compression device

BACKGROUND

The creation of positive pressure pneumoperitoneum (PP) may lead to adverse cardiovascular effects during laparoscopic operations. It can also lead to increased sympathetic cardiac activity, that might have serious consequences. We hypothesized that by reversing the hemodynamic effects, the use of intermittent sequential pneumatic compression device (Lympha-press) on the lower extremities would lead to improved cardiac autonomic control.

METHODS

This was a prospective cohort study, in which patients served as their own control. Fifteen patients without cardiorespiratory disease undergoing elective laparoscopic cholecystectomy were enrolled prospectively. The activity of the cardiac autonomic nervous system was evaluated by using spectral analysis of heart rate variability, with the Del Mar Avionics 363 (Irvine, California), based on the fast Fourier transformation. The Lympha-press was manipulated several minutes after induction of PP. In each frequency band we measured and compared the power values during anesthesia against those of PP, as well as those of PP against those recorded during activation of Lympha-press.

RESULTS

Creation of PP caused increased sympathetic activity, as was manifested by increased power of the low frequency band. Manipulation of the Lympha-Press compression device caused increased parasympathetic activity, as was evident by significant increased power of the high frequency band in all patients.

CONCLUSIONS

Using an intermittent sequential pneumatic compression device during laparoscopic cholecystectomy may improve cardiac autonomic control by enhancing protective parasympathetic activity. That may have clinical significance, especially in patients suffering from cardiac disease, by improving heart rate variability and elevating the threshold of the occurrence of ventricular arrhythmia.

Upper quadrant access for urologic laparoscopy

Initial access into the peritoneum and establishing pneumoperitoneum are required for laparoscopy. Various techniques have been described to achieve insufflation and place trocars. We describe our method of initial entry into the upper quadrant and subsequent incorporation of this site as a working port during upper urinary tract laparoscopy. This is an easy and safe means of entering the peritoneum, even after prior surgery, and provides a functional trocar for retraction and dissection.

Influence of different gases used for laparoscopy (helium, carbon dioxide, room air, xenon) on tumor volume, proliferation, and apoptosis

BACKGROUND

Previous reports suggest that helium pneumoperitoneum used for laparoscopic surgery suppresses postoperative tumor growth. The present study was designed to determine the effects of gases used in laparoscopy on tumor volume, proliferation, and apoptosis in rats with implanted malignoma.

METHODS

In 36 rats Morris hepatoma 3294A cells were implanted intrahepatically. Then, after 5 days, they underwent laparoscopy using helium ( n = 7), CO(2) ( n = 7), room air ( n = 7), or xenon ( n = 8). One group received anesthesia only ( n = 7). Rats were killed 10 days after implantation to assess tumor volume, proliferation, and apoptosis.

RESULTS

Helium pneumoperitoneum caused a significant smaller tumor volume compared to other groups (Kruskal-Wallis test: p = 0.001; median tumor volume: control: 44 mm3; helium: 19 mm3). There was no significant difference in tumor cell proliferation (PCNA) and apoptosis (TUNEL reaction) between the groups.

CONCLUSIONS

There was a significant decrease of tumor volume using helium pneumoperitoneum compared to the other gases, but no decreased tumor cell proliferation or increased tumor cell apoptosis.

Novel approach to minimizing trocar sites during challenging hand-assisted laparoscopic surgery utilizing the Gelport: trans-gel instrument insertion and utilization

PURPOSE

We present a novel technique for modified application of a hand-assist device, the Gelport (Applied Medical Resources, Rancho Santa Margarita, CA), which uses a gel for intra-abdominal access.

MATERIALS AND METHODS

A 53-year-old woman with a history of rectal cancer treated by abdominoperineal resection, ileostomy, subsequent reanastomosis, chemotherapy, and radiation presented with a 6-cm upper-pole left renal mass. Staging was negative, and a CT scan showed no evidence of lymphadenopathy or renal vein involvement. The patient elected to undergo a hand-assisted laparoscopic radical nephrectomy. Numerous intra-abdominal adhesions were encountered during initial periumbilical hand port placement. The initial adhesions were taken down in an open fashion; however, the proposed trocar sites still could not be exposed. The Gelport was placed, and a laparoscope was passed directly through the established central opening and the gel. A working instrument was then passed through the gel itself, allowing adhesiolysis under direct laparoscopic vision.

RESULTS

The nephrectomy was completed laparoscopically in 4 hours and 15 minutes with lysis of adhesion occupying 90 minutes of the operative time. The estimated blood loss was 150 mL. Despite the technical difficulty of the case, the procedure was completed laparoscopically with two standard 12-mm trocars and a 5-mm lateral retraction trocar.

CONCLUSION

The Gelport permits simultaneous insertion of the surgeon's hand and a working laparoscopic instrument. This allows for maximally efficient utilization of the incision made for hand-assist device placement and may minimize the need for additional trocars during challenging laparoscopic cases.

Single cannula technique and robotic telescopic assistance in infants and children who require laparoscopic Nissen fundoplication

BACKGROUND/PURPOSE

Laparoscopic Nissen fundoplication (LNF) is being utilized more extensively in the management of symptomatic gastroesophageal reflux disease in infants and children. The traditional approach utilizes 5 3- to 5-mm cannulas for telescope and instrument access to the peritoneal cavity. The purpose of this study is to report the technique and document the results using a single 5-mm umbilical cannula for LNF, stab incisions for placement of the instruments, and robotic telescope assistance.

METHODS

From November 1999 through March 2002, 154 patients underwent LNF by the senior author for pathologic gastroesophageal reflux disease. All operations were performed with a single 5-mm umbilical cannula through which a 4- or 5-mm telescope was placed for operative visualization. Four stab incisions were made through the upper/lateral abdominal wall under direct visualization avoiding the epigastric vessels. Through these stab incisions, instruments were inserted into the peritoneal cavity. The maximum insufflation pressure was 15 mm Hg in all cases. The ability to perform the procedure in the absence of additional operative cannula placement, complications during instrument insertion, the ability to maintain adequate pneumoperitoneum, the patient's age, weight, operating time, and the addition of a gastrostomy were recorded.

RESULTS

All but one of the 154 LNFs were completed successfully using this technique. The mean age at operation and mean operating time was 23.9 months (range, 3 weeks to 180 months) and 91 minutes (31 to 160 minutes), respectively. Patients weight ranged from 2.4 to 57 kg (mean, 10.4 kg). Gastrostomies were placed in 52 cases. There were no complications associated with the stab incisions or insertion of the operative instruments through the abdominal wall. Pneumoperitoneum was maintained adequately in all cases.

CONCLUSIONS

LNF can be performed safely and effectively with a single umbilical cannula. We recommend its use for pediatric patients who require LNF.

Periumbilical veress needle pneumoperitoneum: technique and results in 2.126 cases

In laparoscopic surgery, a pneumoperitoneum is generally created either by direct puncture (Veress needle technique) or by the open (Hasson) technique. Some surgeons predominantly use direct access, reserving open access for selected patients; others consider the Veress needle as carrying an unacceptable risk of intestinal or vascular injury and consequently use only the Hasson technique. The database containing records of all abdominal laparoscopic operations performed in our institution was reviewed; over the period from June 1991 to December 2001 a total of 2,126 laparoscopic operations were performed, consisting in 1,457 (68.5%) cholecystectomies, 392 (18.4%) appendectomies, 177 (8.3%) varicocelectomies, 65 (3%) operations on the uterus and ovaries, 6 (0.2%) groin hernia repairs, 6 (0.2%) fundoplications, 3 (0.1%) ileo-colic resections for right colon cancer, and 20 (1.3%) diagnostic laparoscopies. The direct puncture technique was used in 100% of cases. The time needed up to connection of the video camera averaged 4-7 minutes. Twelve laparoscopic cholecystectomies were converted, with a conversion rate of 0.5%. Four patients were re-operated on, two for bleeding from the gallbladder fossa and two because of small bowel perforation caused by electrocautery. None of the patients sustained any clinically apparent vascular or bowel injury as a result of the blind access. There were no cases of preperitoneal or omental air insufflation. The mortality was nil. The authors describe their technique for gaining access to the abdominal cavity by direct puncture and conclude that properly performed Veress needle insertion is less invasive, safe and perfectly feasible in all patients.

The spinal needle test effectively measures abdominal wall thickness before cannula placement at laparoscopy

STUDY OBJECTIVE

To demonstrate the usefulness of the spinal needle test at laparoscopy to correlate abdominal wall thickness at initial entry sites with body mass index (BMI).

DESIGN

Prospective cohort study (Canadian Task Force classification).

SETTING

University-affiliated hospital.

PATIENTS

One hundred thirty-eight women.

INTERVENTION

Diagnostic laparoscopy.

MEASUREMENTS AND MAIN RESULTS

After CO(2) insufflation, the spinal needle test was performed by inserting a spinal needle attached to a partially filled syringe and advancing it perpendicular to the skin until the gas pocket was reached. To improve precision, the distance was measured 3 times at two sites, the umbilicus and Palmer's point (left upper quadrant). Patients' mean BMI was 25.8 kg/m(2) (range 17.2-60.0 kg/m(2)), with 24 (17%) considered clinically obese (BMI > or =30 kg/m(2)). A significant correlation was noted between BMI and abdominal wall thickness at the umbilicus (R = 0.69) and left upper quadrant (R = 0.81). Excellent correlation was also noted between body weight and thickness at the two points (R = 0.72 and R = 0.78, respectively). The mean thickness at the umbilicus differed significantly between obese (3.0 +/- 1.2 cm) and nonobese women (1.7 +/- 0.7 cm, p <0.001); as did mean thickness at the left upper quadrant (4.4 +/- 1.0 vs 2.0 +/- 0.7 cm, p <0.001).

CONCLUSION

Thickness of the abdominal wall at umbilical and left upper quadrant entry sites correlates well with weight and BMI. Even among obese women, the distance to the pocket of gas after insufflation at either entry site is remarkably small.

Laparoscopic enucleation of an insulinoma: advantages of using the curved laparoscopic coagulating shears

Laparoscopic excision is a widely accepted and well-described approach to islet cell tumors of the pancreas. We report the case of a patient with biochemically proven insulinoma who underwent successful enucleation using the curved laparoscopic coagulating shears. We discuss the advantages of using laparoscopy to manage these tumors and the increased benefit of using the curved instrument for this type of procedure.

[The status of port-site recurrence]

Since laparoscopic surgery has been applied to cancer, an increased number of secondary tumors implanted in the abdominal wall have been reported. Quality of surgery is paramount in the incidence of port-site recurrences. In large prospective series of laparoscopic colorectal surgery, their incidence (around 0.85%) was similar to that reported in open surgery (0.6 to 1.6%) while it is higher for unapparent gallbladder cancer (around 15%) due to direct wound contamination. Viable tumor cells are seeded by inadequate surgical technique or released by advanced tumors. Tumor cells are carried across the abdominal cavity by peritoneal fluid currents and surgical instruments, not by CO2 pneumoperitoneum. CO2 modifies the morphology of mesothelial cells and inhibits peritoneal macrophages. Differences in retroperitoneal/subserosal/intraluminal tumor xenograft models show that CO2 laparoscopy reduces tumor growth when compared to gasless laparoscopy and laparotomy. The local effects of pneumoperitoneum in the wound might be counteracted by using inert gases such as helium, drug-loaded CO2 or various antiadhesive or cytotoxic agents. In clinical practice, port-site recurrences can be effectively prevented by careful surgical technique and prophylactic wound irrigation.

[Splenic lesions as a complication of pelviscopy]

Splenic lesions as a complication of pelviscopy. The induction of pneumoperitoneum for diagnostic pelviscopy caused a splenic lesion as a result of stretching and distorsion of perisplenic adhesions. It will be discussed forensic problems.

[Laparoscopic hand-assisted operation. Review of the literature and initial personal experiences with the HandPort System]

BACKGROUND

During complex laparoscopic operations sometimes the situation of a "missing hand" will occur. Using a device for hand assistance, the surgeon can place one hand into the abdominal cavity to assist the laparoscopic procedures.

METHOD

After a laparotomy of 7-8 cm length, the surgeon can bring one hand into the abdomen via a special device maintaining the pneumoperitoneum. This hand can be helpful, i.e. for exploration, for retraction of gut and organs or for extraction of the specimen. Indications are complex laparoscopic operations such as stomach or colonic resections or splenectomies. In obese patients or patients with extended adhesions, preparation can be facilitated.

RESULTS

The literature review and the author's own results with 10 patients since 2000 show remarkable advantages in operative situations when the laparoscopic procedure is complicated or even impossible. In our 10 patients, all operations could be managed laparoscopically by using the HandPort device.

CONCLUSIONS

Complicated operations can be performed laparoscopically without conversion to conventional laparotomy by using the hand assistance. These patients do not have to forgo to the benefit of minimally invasive operations.

[The manufacture of the pressure transducer for medical Solos Insufflator]

A 0-10 Kpa pressure transducer and its circuit are presented in the paper, which can be used as a substitute for the integrated pressure transducer in medical Solos Insufflator and can be used too in other devices and equipments.

Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures

BACKGROUND

The use of the Veress needle in laparoscopy to create the pneumoperitoneum has inherent risks; it may cause vascular and visceral injuries. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming. One alternative is to enter the abdomen using an optical trocar under direct view. Our aim was to determine whether the optical access trocar can be used to effect a safe and rapid entry in various laparoscopic procedures.

METHODS

Over a 4-year period, the Optiview trocar was used for initial entry in 650 laparoscopic procedures. The procedures included cholecystectomy (n = 282), transabdominal inguinal hernia repair (n = 76), radiofrequency ablation of liver tumors (n = 73), adrenalectomy (n = 54), appendectomy (n = 41), colorectal surgery (n = 39), and various other procedures (n = 85). The following parameters were analyzed: presence of previous abdominal operations, site and duration of entry, and complications.

RESULTS

Of the 650 patients, 156 (24%) had had previous abdominal operations. In 25 cases, previous trocar sites were reused for optical access. The optical trocar was inserted at the umbilicus in 495 patients (76%), in the right upper quadrant in 77 (12%), in the left upper quadrant in 26 (4%), in the upper midline in eight (1%), in the right lower quadrant in six (0.9%), and in the left lower quadrant in three (0.5%). In 35 patients undergoing posterior adrenalectomy, optical trocars were used to enter Gerota's space. Mean (SD) entry times were 92 (45) sec at the umbilical site, 114 (30) sec at the back, and 77 (35) sec at the remaining sites. Complications (0.3%) included one injury to the bowel and one injury to the gallbladder; however, they were recognized and repaired immediately.

CONCLUSIONS

To our knowledge, this report comprises the largest series in which the optical access trocar was used for laparoscopic surgery. This device provides the basis for a safe and fast technique for initial trocar placement: it also has the potential to reduce costs. Thanks to our favorable experience, the optical trocar method has become the standard technique for abdominal access in our laparoscopic practice since 1995.