laparoscopy

Question 1

what are alternative trocar entry sites and why use them

Answer 1

• palmers point ( preferred except in cases of previous surgery in this area or splenomegaly)
• suprapubic insertion of veress ( risk of bladder injury)
• uterine fundus with veress needle ( risk of infection and bowel injury if adherent bowel to fundus)
• posterior fornix (risk of bowel injury)

consider alternative entry point after 3x failed attempts at umbilicus. Also consider if prior surgery: rate of adhesion formation at umbilicus following midline laparotomy may be 50% and 23% in lower transverse incision

Question 2

Describe palmers point entry

Answer 2

• lying flat
• NGT to reduce distension of stomach for anaesthetic gases
• discuss with anaethetist
• palpate for palmers point- left midclavicular line 3cm below costal edge
• small incision
• veress needle inserted vertically
• test for correct placement with pressure/ flow test
• CO2 to 25mmHg then 2-5mm endoscope to view undersurface of anterior abdominal wall,
• if free of adhesions insertion of trocar under direct vision
  if too many adhesions, direct free with secondary ports or alternative placement under direct vision.

Question 3

How should the closed laparoscopic entry technique be performed

Answer 3

• operating table horizontal
• abdomen should be palpated to check for any masses and for the position of the aorta before insertion of the Veress needle.
• primary incision vertical from the base of the umbilicus
• The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria.
• The lower abdominal wall should be stabilised 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.
• 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.
• placement of veress needle tested
• An intra-abdominal pressure of 20–25 mmHg
• 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.
• 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.
• If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site should be visualised from a secondary port site, preferably with a 5-mm laparoscope.
• 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.

Question 4

How to check correct placement of veress needle?

Answer 4

• Once the Veress needle tip is in the peritoneal cavity, the clinician may consider the aspiration and saline drop tests. It should be noted that these tests have moderate sensitivity and specificity for correct entry only.
• xThe test with the highest sensitivity and specificity is immediate gas pressures and 5 successive pressures of <8mm Hg have a high correlation with correct Veress needle placement.

Question 5

How should the open laparoscopic entry technique be performed

Answer 5

The Hasson technique of open laparoscopic entry is an alternative to closed laparoscopy that avoids the use of sharp instruments after the initial skin incision
It allows the insertion of a blunt-ended trocar under direct vision.
Once the fascial edges are incised, they should be held by a lateral stay suture on either side of the incision. Once the peritoneum is opened, the fascial sutures are then pulled firmly into the suture holders on the cannula to produce an airtight seal with the cone of the cannula. Gas is insufflated directly through the cannula to produce the pneumoperitoneum.
The blunt trocar is withdrawn only after the abdomen is partially distended.
At the end of the procedure, the fascial defect should be closed using the stay sutures (and possibly additional sutures) to minimise the risk of herniation.

Question 6

risks of laparoscopic entry

Answer 6

Serious risks:

• The overall risk of serious complications from diagnostic laparoscopy is approximately 2 in 1000 women (uncommon). This includes damage to the bowel, bladder, ureters, uterus or major blood vessels which would require immediate repair by laparoscopy or laparotomy (open surgery is uncommon). However, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy.
• Failure to gain entry to the abdominal cavity and to complete the intended procedure.
• Hernia at site of entry (less than 1 in 100; uncommon).
• Thromboembolic complications (rare or very rare).
• Death; 3–8 in 100 000 women (very rare) undergoing laparoscopy may die as a result of complications.

Frequent risks are usually mild and self-limiting.They may include:

• bruising
• shoulder-tip pain G wound gaping
• infection.

Question 7

how should secondary ports be inserted?

Answer 7

• Secondary ports must be inserted under direct vision perpendicular to the skin, while maintaining the pneumoperitoneum at 20–25 mmHg.
• During insertion of secondary ports, the inferior epigastric vessels should be visualised laparoscopically to ensure the entry point is away from the vessels.
• During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.
• Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed and treated, if present.

Question 8

Describe insertion of veress needle

Answer 8

Insertion of Veress
• The tap should be open
• The abdominal wall may be splinted with the non-dominant hand. The skin may be elevated and it is
important to note that this manoeuvre changes the shape of the peritoneal cavity but not the volume and does not decrease the risk of injury to intraperitoneal contents such as bowel but may decrease the risk to retroperitoneal structures such as vessels by changing the perpendicular distance.
• With the dominant hand, the Veress needle should be held a few centimetres above the needle tip rather than on the needle waist to avoid deep or uncontrolled insertion
• Using continuous pressure the needle is inserted at the base of the umbilicus where there is the least distance to be traversed directly perpendicular.
• The surgeon may have the sensation of a single or dual loss of resistance (a ‘pop’) pending the tip location and its passage through the fascia.
• Only the tip of the Veress needs to be inserted to commence insufflation and assess pressure

Question 9

If placement of the Veress needle is considered to be incorrect following 3 attempts consider the following:

Answer 9

• Seek assistance from a senior colleague
  • Choose an alternate site for placement such as the left upper quadrant
  • Choose an alternate entry type such as open entry
  • Cease the procedure completely