1. RCOG Basic Practical Skills Course
Laparoscopy and entry
RCOG Basic Practical Skills Course

2. Laparoscopic entry techniques
What to expect:
Position of patient
Primary port closed entry
Secondary port entry
Primary port alternatives
Exit techniques
Reference to RCOG Green Top Guideline 49 - PREVENTING ENTRY-RELATED GYNAECOLOGICAL LAPAROSCOPIC INJURIES

3. 1. Position Prone Stirrups/Lloyd Davis Non slip mattress
Trendelenberg after ports

4. Green-top Guideline. No. 49 May 2008
The operating table should be horizontal (not in the Trendelenberg tilt) at the start of the procedure
The abdomen should be palpated to check for any masses before insertion of the Veress needle

5. 2. Primary port closed entry
Why intra umbilical entry?
Fixed peritoneum
Thin
Least vascular
Cosmetic

6. Green-top Guideline. No. 49 May 2008
The primary incision for laparoscopy should be vertical from the base of the umbilicus (not in the skin below the umbilicus)
Care should be taken not to incise so deeply as to enter the peritoneal cavity.

7. 2. Primary port closed entry
Insertion of Veress needle
Pencil grip
Vertical, then towards pelvis
Double “click”

8. Green-top Guideline. No. 49 May 2008
The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended
The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at right angles to the skin

9. Green-top Guideline. No. 49 May 2008
Two audible clicks are usually heard as the layers of the umbilicus are penetrated.
Excessive lateral movement of the needle should be avoided. This may convert a small needle point injury in the wall of the bowel or vessel into a complex tear

10. 2. Primary port closed entry
Saline test
Withdraw
Instil
If no fluid, frank blood (or faeces) then proceed with insufflation

11. Green-top Guideline. No. 49 May 2008
The saline test not 100% accurate
The most valuable test of correct placement of the Veress needle is to observe that the initial insufflation pressure is relatively low (less than 8mmHg) and is flowing freely
After 2 failed attempts to insert the Veress needle, either the open Hasson technique or Palmer’s point entry should be used.

12. 2. Primary port closed entry
Insufflation
Set pressure cut off to at least 20-25mmHg
Start at low flow (1L/min)
Check gas entering at low pressure (<8mmHg)
After 0.5L flow rate can be increased
Insufflate to pressure cut off (20-25mmHg)

13. 2. Primary port closed entry
The greater the gas bubble & abdominal wall tension the less the risk of bowel injury
Abdominal pressure= 8mmHg
Abdominal pressure=25mmHg

14. Green-top Guideline. No. 49 May 2008
An intra-abdominal pressure of 20–25 mmHg should be achieved before inserting the primary trocar
The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete

15. Green-top Guideline. No. 49 May 2008
The primary trocar should be inserted at 90 degrees to the skin, through the incision at the base of the umbilicus
Once the laparoscope has been introduced it should be rotated through 360 degrees to check for any adherent bowel

16. 2. Primary port closed entry
Commonest problem - failed entry
Insertion of subumbilical Veress needle

17. 2. Primary port closed entry
Closed entry can still cause bowel injury, especially if adhesions are present

18. 2. Primary port closed entry
Other injuries
Vascular injury
Retroperitoneal haemorrhage
Bladder injury
Injury to over inflated stomach

19. 3. Secondary ports
Secondary ports are inserted under direct vision - an inadvertent injury from a secondary port could be considered negligent”
Principles
Avoid inferior epigastric vessels
Avoid bowel/vascular injury
Minimise hernia risk

20. Green-top Guideline. No. 49 May 2008
Secondary ports inserted under direct vision at right angles to the skin at 20–25 mmHg pneumoperitoneum
Inferior epigastric vessels should be visualised laparoscopically prior to secondary port placement
Once the trocar has pierced the peritoneum it should be angled towards the anterior pelvis

21. Obliterated umbilical artery
3. Secondary ports - Anatomy
Round ligament
Obliterated umbilical artery
Rectus muscles
Mid-line

22. 3. Secondary ports - Anatomy
Inf epigastric artery

23. 4. Primary port – Alternatives
Alternatives to closed umbilical entry considered:
If there is risk of umbilical adhesions - previous (midline) laparotomy
In very slim or morbidly obese women
Failed saline test or Veress insertion x2
Unsatisfactory closed Veress insufflation
Alternatives include:
Open entry – variations of Hassan technique
Palmer’s point closed entry

24. Green-top Guideline. No. 49 May 2008
When Hasson open laparoscopic entry is employed, confirm that the peritoneum has been opened by visualising bowel or omentum
Palmer’s point is the preferred alternative trocar insertion site, except in cases of previous surgery in this area or splenomegaly.

25. 5. Exit techniques Under direct view to identify: Bleeding
Injury to omentum
Injury to bowel
- (partial/complete)

26. Green-top Guideline. No. 49 May 2008
On removal of a laparoscope. Check by direct visualisation that there has not been a through-and-through injury of bowel adherent under the umbilicus
Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed and treated, if present.

27. 5. Exit techniques Wound closure:
Proper closure of fascia within umbilical port site to prevent wound dehiscence or hernia
Avoid hernia risk by closing sheath:
- Midline port sites > 7mm
- Lateral port sites > 5 mm

28. Now show the Video: Closed laparoscopic entry technique
Now show the video: Alternative
laparoscopic entry techniques