Laparoscopic Access Technique

 

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Laparoscopic techniques have revolutionized the field of surgery with benefits that include decreased postoperative pain, earlier return to normal activities following surgery, and fewer postoperative complications (eg, wound infection, hernia). However, unique complications are associated with gaining access to the abdomen for laparoscopic surgery. Inadvertent bowel injury or major vascular injury is uncommon, but both are potentially life-threatening complications that are most likely to occur during initial access technique by new surgeon and gynecologist during their learning curve.

The blind Veress needle/trocar insertion and open trocar placement under direct visualisation are the two most common techniques used to gain entry into the peritoneal cavity during laparoscopic general surgery. Gas insufflation is used to establish pneumoperitoneum and enable visualisation of abdominal structures once entry to the peritoneal cavity has been achieved. Many of the complications associated with operative laparoscopy such as subcutaneous emphysema and gas embolism laparoscopy arise from creation of the pneumoperitoneum, or from injury to internal structures during abdominal entry.

Much of the information relating to these types of complications are associated with minimally invasive gynaecologic procedures because of the relative infancy of laparoscopic general surgery. General surgical interventions are typically more complicated, are more likely to be performed in older patients, require longer operative times and a greater number of access sites, compared to gynaecologic laparoscopy. Therefore, laparoscopic general surgery have higher complication rates associated with pneumoperitoneum or abdominal entry, making selection of a blind versus open access technique more important.

Acess Technique needs proper explanation depending upon which technique you are using. . Left upper quadrant (LUQ, Palmer’s) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. Other sites of insertion, such as transuterine Veress CO2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels.

Veress intraperitoneal is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO2 source to the Veress needle on entry. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 in non-obese women to 90 in obese women.

The volume of CO2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO 2 volume. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women.

The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars.

The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury.