1. Safe Laparoscopic Access: technologies and techniques
洪煥程 醫師
台北榮總 婦產部
96-1-2

2. Laparoscopic Abdominal Entry
Laparoscope-related complications were reported with increasing frequency during growing phase of laparoscopic surgery.
Entering the abdomen is the most dangerous part of the laparoscopic procedures.

3. Laparoscopic complications
general-anesthesia-related
injuries to the vascular system, bladder, and bowel.
These injuries
indirect injury due to the use of monopolar current
now more commonly ascribed as direct trauma caused by the insertion of the insufflation needle or the primary or secondary trocars
Injuries occur more frequently as a result of the placement of the insufflating needle or primary trocar placement.
Levy BS 1985; Reich H 1995

4. Laparoscopic complications
Most complications during laparoscopy occur during the surgeon’s first 100 cases.
Soderstrom RM et al.
Operative Laparoscopy: The Master’s Technique.
1993

5. Laparoscopic Abdominal Entry
Approaches to initial cannula
Closed insertion without preinsufflation
Closed insertion with preinsufflation
Open laparoscopy

6. Superficial anatomy of the anterior abdominal wall

7. Anatomic landmarks Umbilicus: at the level of L3 and L4
Abdominal aorta: bifurcation L4 and L5

8. Placement of the Veress needle
Umbilical area
Lower edge
Adequate size
Complete horizontal position

9. Placement of the Veress needle
The angle insertion : 45 degree from the surface of skin, more vertical orientation in obese women
Aim toward uterus
Aim away from pelvic vessels (vertical; sagital)
Aim at right angle to the skin

10. Placement of the Veress needle
Palpating the aorta and sacral promontory
Grasp the base of umbilicus : keep Veress needle from the abdominal structure

11. Placement of the Veress needle
Using towel clips to elevate the abdominal wall

12. Tests of peritoneal insertion
Drop test (Epidural space test):
- a drop of water --- suctioned into
peritoneal cavity
Syringe barrel flow test:
Manometer test (free flow of gas):
- elevation of abdominal wall, falling
insufflation pressure ( < 5-6 mmHg at
1.0L/min flow )
Loss of liver dullness early in insufflation

13. Tests of peritoneal insertion
Aspiration-instillation-aspiration test (Syringe aspiration test):
- Aspiration : blood, bile, bowel content, urine
- Instillation : 10cc N/S--- if any resistant
- Re-aspiration : no fluid aspirated
Waggling test (Lateral needle swing test): (potentially dangerous)
- base on tactile confirmation of a free-
moving tip
- pivot point at the tip --- adhesion or pre-
peritoneal
- pivot point at the fascia --- intraperitoneal

14. Tests of peritoneal insertion

15. Tests of peritoneal insertion

16. Recommended amount of gas for initial insufflation with a Veress needle
Monaghan
2-4 L
Sutton
About 3 L
Gordon
1-2 L
Soderstrom
Pressure (not specified)
Deprest & Brosens
Preset pressure (not specified)
Bruhat
Not specified
Hulka & Reich
20-25 mmHg
Tompson & Rock
Should not exceed 10 mmHg
Tulandi
2-3 L (usually)

17. Primary trocar insertion
Patient in a horizontal position
Skin incision should be large enough to prevent any resistance
A stretched middle finger can prevent over-insertion (palming technique)
Z-technique ? (prevention of incision hernia)

18. Primary trocar insertion Z-technique

19. Direct trocar insertion without preinsufflation
First described by Dingefelder (1978)

20. High risk conditions for abdominal entry
Strong abdominal musculature (sportswomen)
Body weight is obese or very thin
Large pelvic mass
Pregnancy
Previous abdominal and pelvic operations

21. In Morbid Obese Patients

23. The Incidence of Adhesions After Prior Laparotomy ? (N=360)
Adhesion bowel omentum
Pfannenstiel : % %
Midline below the umbilicus : % %
Midline above the umbilicus : % %
Subjects with all types of incision :
Gynecologic (42 %) > Obstetric (22%)
Brill AL: Obs Gyn 1995, 85:269-72

24. Management of abdominal wall access with probable intraperitoneal adhesion
Exploratory syringe aspiration test
Direct Veress needle with optic catheter
Open laparoscopy
Alternative access

25. Exploratory syringe test (Syringe aspiration test)
To ascertain : no bowel/vessels adherent under the umbilicus before trocar insertion
After pneumoperitoneum created by Veress needle, a 20-gauge needle inserted under negative pressure at the four cardinal points of a 20-mm circle around the umbilicus ---
alternate sites trocar if blood or bowel content is aspirated

26. Direct Veress needle insertion with optic catheter ( needle scopy)
1.2mm, 1.75mm, 1.98 mm
Visual control via optics inserted into
needle

27. Open laparoscopy 1971, Hasson
A horizontal/vertical incision about 2 cm
Enter peritoneal cavity by incision of abdominal wall step by step
Apply Hasson trocar-cannula and purse-string suture at fascial level

28. Open laparoscopy

29. Alternative access sites
inter/infracostal area :
- the 9th intercostal space in the middle of the mid-clavicular & the ant axillary line
Lt costal margin :
- 3-4 cm below the left costal margin in the mid-clavicular line
- Reverse Trendelenburg position
- First to rule out splenomegaly or insufflated stomach ( on NG )

30. Alternative insertion sites

31. Alternative needle insertion sites
Lt periumbilical area :
- midclavicular line
Transvaginal insertion :
- via post cervix fornix, trendelenburg
position
Transabdominal insertion :
- Pushed uterus up against the abdominal,
then inserted through abdomen and into
fundus of the uterus

32. Alternative access - the Lee-Huang point

33. Storz TERNAMIAN EndoTIP ( Endoscopic Threaded Imaging Port )
Re-usable trocar
After umbilical incision and Veress insufflation, a 0° laparoscope is mounted in the cannula. The tip of the cannula is inserted into a tiny fascial incision and rotated clockwise
All the abdominal wall layers are well visualized

34. Blunt Trocar
is used to safely create a Pneumoperitoneum in the scarred abdomen
fascial incision should be 1 to 1.5 cm in size
A long suture is placed on each fascial edges
finger dissection a tunnel or an opening into the intraabdominal cavity is gently created
The foamgrip anchoring device is set and secured with the previously placed suture

35. VISIPORT™ A 1 cm skin incision
A telescope is inserted into the trocar and the path of entry of the trocar into intra-abdominal cavity is visualized
These planes are cut slowly with the blade of the trocar (at the tip of the instrument)
Pneumoperitoneum must be created or abdominal wall elevation must be performed prior to the insertion

36. VERSASTEP SYSTEM™
an integrated system combining a Nylon stretchable sheath over a Disposable Veress needle
Once inserted, the sheath is dilated by inserting the trocar (with a dilator in place)
no cutting entry blade
decreasing trocar site bleed and the potential for an intra-abdominal injury
creates a smaller fascial defect which does not need to be closed
up to 12mm

37. VERSASTEP SYSTEM™

38. Secondary trocar insertions
Off the midline, to the left, above the pubic hairline
Transillumination and under endoscopic direct vision helps to identify the vessels.
and minimizing the risk of injury
Deep Inferior epigastric <-- ext. iliac
Superficial epigastric <-- femoral
Lateral to the rectus abdominis muscle
Lateral to the umbilical ligaments
Lateral to the deep epigastric vessels
Aiming toward the uterus (cul-de-sac) and away from the iliac vessels
Keeping the forefingers extended on the sleeve

39. Conclusion - 1
The incidence and spectrum of access-related complications is greater than previously perceived.
Newer devices and modifications in technique may reduce the incidence of such adverse events.

40. Conclusion - 2 Put patient in a proper position
Understand anatomical relation
Follow the abdominal entry principles
Be aware of high-risk conditions
Use proper instruments and alternative strategies

41. Q 1 The angle insertion of Veress needle
? degree from the surface of skin ( more obese)
1. 30 degree
2. 45 degree
3. 90 degree
4. 0 degree

42. Q 2 1. Superficial circumflex iliac a. 2. Superficial epigastric a.
What vessel injury related to peritoneal hematoma during lat. trocar insertion ?
1. Superficial circumflex iliac a.
2. Superficial epigastric a.
3. Deep circumflex iliac a.
4. Deep inferior epigastric a.