Module 6

Question 1

what is a veress needle?

Answer 1

Spring loaded needle with sharp outer needled and blunt inner needle

Blunt inner needle is conduit for insufflation gas

Question 2

how is the Veress needle inserted?

Answer 2

Make incision through skin and subq Q to allow tip of needle to pass through
Size determined by trocar size

Locations:
Skin can be made in periumbilical skin fold or center of umbilicus
Other safe entry point is LUQ (Palmer’s point)

Reviewed previous op reports
Note that mesh may extend past area of incision
**Should use open entry anytime there is concern/uncertainty about mesh or adhesions below entry site

Question 3

how to choose entry site with Veress needle?

Answer 3

Umbilicus: most common because abdominal wall thinnest at this point and centrally located

Choose other location if umbilical scars, umbilical hernia repair, or not optimal location for operative site
LUQ (Palmer’s point)
Make sure to stay lateral to epigastric vessels if off midline
Can do veress or optiview or direct entry at this site

Question 4

steps of Veress entry

Answer 4

Abdominal wall lifted up by surgeon and assistant -> creates safe distance between anterior abdominal wall and aortoiliac vessels

Verres needle held like pencil, passed through skin incision perpendicular to abdominal wall

Once spring loaded portion passes through peritoneum, audible click and blunt tip now exposed

Question 5

ways to see if veress needle is in correct spot

Answer 5

• Freely mobile tip
• Connect tubing and initiate gas at low flow rate, pressure should be low
• No aspiration of blood or enteric contents
• Free flow of saline
• Hanging drop test
• Tympany with percussion after insufflation

Question 6

relative CIs to blind insertion of first trocar

Answer 6

Previous abdominal surgery
Previous inflammatory process

Question 7

absolute CIs to blind insertion of first trocar

Answer 7

Abdominal scar from prior open operation in area of trocar insertion
Previously placed mesh for hernia repair

Question 8

How to place trocar?

Answer 8

Place trocar in palm of hand, shaft between index and middle fingers
Keep wrist straight
Use twisting motion with pushing motion

Trocar tips: bladed, spring loaded, optical, blunt tipped, etc.

Question 9

complications from veress/trocar insertion

Answer 9

bowel injury, omental/mesenteric vascular injury, RP vascular injury, cardiac arrhythmia, hypotension, high airway pressures, pneumothorax, gas embolism

Question 10

when should you use a hasson trocar?

Answer 10

Used for patients with or without hx of abdominal surgery

May perform away from previous scar

**Does NOT decrease risk of inadvertent organ injury, but more likely to DETECT injury

Answer 11

1. Make 2cm vertical or horizontal skin incision
2. Incision carried down to fascia, can elevate fascia with kocher
3. Incise fascia with scalpel or Bovie
4. Place anchoring sutures in fascia while good exposure (use 0 or 2-0 absorbable suture)
5. Dissect through pre-peritoneal fat, and then lift up peritoneum with two clamps, and then incise peritoneum with scissors or scalpel
6. Once opening made, blunt tipped trocar is inserted and secured with stay sutures

**STILL need to inspect after insertion