Camran Nezhat, Ceana Nezhat, Farr Nezhat, Roger Ferland, Michael Lewis, and Louise P. King
In 1954, Palmer reported the results of abdominal endoscopic procedures in 250 patients without sequelae. Pneumoperitoneum was produced with CO2 at a rate of 300 to 500ml/min and the author cautioned that the intra-abdominal pressure should not exceed 25 mmHg.1 The claimed advantages of laparoscopy over culdoscopy were decreased chance of infection, a better view of the pelvis, improved access to the pelvic organs and cul-de-sac, and easier application of surgical techniques.
The benefits of laparoscopy were only truly realized with the introduction of videolaparoscopy in 1986.2 Prior to the advent of videolaparoscopy, the utility of laparoscopy was diminished by two major drawbacks. First, the surgeon had to work crouched over the patient and could only visualize the intra-abdominal cavity with one eye. Thus, visibility was limited and the position was uncomfortable limiting the ability to perform difficult procedures. Second, only the surgeon had a view of the operative field; the remainder of the surgical team was “in the dark” and unable to anticipate the surgeon’s needs. Both of these limitations were rectified with the incorporation of higher resolution videolaparoscopy in the late 1980s. Using videolaparoscopy, the senior author was able to treat extensive endometriosis with minimally invasive techniques.2 Given the complexity inherent in surgical treatment of extensive endometriosis and the fact that it can be successfully managed with operative laparoscopy, it seems evident that, in the hands of a well-trained laparoscopic surgeon, any pathology encountered can be successfully managed endoscopically. The benefits of videolaparoscopy have facilitated the transition from laparotomy to laparoscopy for multiple procedures including those as uncomplicated as appendectomy and cholecystectomy as well as more complicated procedures such as bowel resection.
Operative videolaparoscopy offers several important benefits over open techniques. Pelvic and abdominal anatomy are magnified by the video camera and laparoscope which facilitates not only full recognition of all evident pathology but also adequate treatment by microsurgical techniques when indicated. The pressure created by the pneumoperitoneum decreases bleeding and provides a clean operating field. The surgeon is more easily able to evaluate and treat the upper abdomen, posterior cul-de-sac, and posterior aspect of the broad ligaments. Laparoscopic surgery creates fewer adhesions than conventional open procedures. When performed by a trained and experienced surgeon, laparoscopy involves fewer intra-operative and postoperative complications.3 A recent meta-analysis has established that the risk of minor complications is significantly less with laparoscopy than with open procedures while the risk of major complications is similar.4 A Cochrane review of trials concluded that laparoscopic surgery for benign ovarian tumors is associated with reduced risk of any adverse effect of surgery, reduced pain, and fewer hospital days when compared with laparotomy. There was no difference between the two approaches with regard to postoperative infectious complications or tumor recurrence.5
In summary, operative videolaparoscopy offers multiple benefits over open surgery. Access into the abdomen is one of the main challenges of laparoscopy. Up to 50% of major complications in laparoscopic surgery occur upon entry and prior to commencement of the intended procedure.6-11 This complication rate has remained unchanged over the past 25 years.12 In the chapter that follows we will present information for residents and surgeons regarding techniques for access to facilitate safe incorporation of videolaparoscopic surgery into their practice.
Advanced operative laparoscopy is a major intra-abdominal procedure. Careful preoperative evaluation optimizes the operative outcome and decreases the incidence of injuries and complications. Preoperative consultations with surgeons in other disciplines (colorectal, urologic or oncologic) may sometimes be necessary. The patient should be informed about the possible outcome and results of the planned operation, possible complications and the surgeon’s experience in doing the particular procedure.
The following preoperative workup is suggested:
1. History and physical
2. Complete blood count (CBC) with differential
3. Serum electrolytes
5. Thrombin time, partial thrombin time, bleeding time
6. Imaging as indicated (most cases require at least transvaginal sonography)
In special situations endometrial biopsy, cervical culture, hysterosalpingogram, barium enema, intravenous pyelogram, magnetic resonance imaging, blood type and screen or type and crossmatch may be indicated.13
Generally, mechanical bowel preparations are no longer recommended for gynecologic surgery even in patients with a history of prior surgery in which bowel injury may be more likely. Studies conducted by colorectal surgeons have shown that mechanical bowel preparation may actually increase the likelihood of spillage of bowel contents. This may be because of the large volume of liquid colonic contents that results from mechanical bowel preps.14 Meta-analysis has shown no advantage to bowel preparation and consequently we do not routinely use mechanical bowel preparation in our patients.15,16 We do recommend a clear liquid diet the day before surgery. We also ask that patients perform up to three enemas the night before surgery to decompress the rectum and allow for better visualization of the posterior cul-de-sac. We also continue to administer antibiotics preoperatively to lower the concentration of colonic bacterial flora in our patients with complicated past surgical history.17
Patient Positioning and Preparation for Laparoscopy
The patient is usually brought to the operative suite and moved onto the operating table by the anesthesiology team and circulating nurse. Once the anesthesiologist has induced endotracheal anesthesia, the surgeon will position the patient in lithotomy. The patient’s legs are placed in padded Allen stirrups ensuring proper positioning to avoid hyperflexion of the legs that could cause compression of the femoral nerve or excessive pressure from the stirrups on the peroneal nerve. The patient’s buttocks should extend beyond the edge of the table by a few centimeters to allow room for uterine manipulation. The patient’s arms should be tucked. Once the patient is properly positioned, a complete pelvic examination is performed including a rectovaginal exam. The patient is then shaved and a bactericidal solution is used over the abdomen, perineum and vagina. After the patient is draped and all instruments tested and secured, the foley catheter is inserted. If indicated, a diagnostic hysteroscopy can be performed prior to entry with the laparoscope. After completing the hysteroscopy, a uterine manipulator is inserted into the cervical os to manipulate the uterus and for chromopertubation.
Serious complications may occur during insertion of the Veress needle and the trocars. The following factors increase the risk of injury:
1. Previous abdominal and pelvic operations
2. Extremes of body habitus (obese or very thin)
3. A large uterus and/or the presence of a large pelvic mass
The optimal location for the insertion of the Veress needle and the primary trocar is the umbilicus. The dermis is attached to the fascial layer and anterior parietal peritoneum with no intervening subcutaneous fat or muscle. Thus, the umbilicus represents the shortest distance between the dermis and the peritoneal cavity even in obese patients allowing for ease of entry. Nevertheless, certain clinical scenarios will require that the primary trocar be inserted elsewhere. For example, in patients who have an enlarged uterus caused by a uterine leiomyoma or pregnancy or in patients undergoing para-aortic lymph node dissection, the primary trocar is inserted approximately 4 to 6 cm above the umbilicus.
Before the needle is inserted, a transverse or vertical cutaneous incision is made in the fold of the umbilicus large enough to accommodate the primary trocar. A vertical umbilical incision provides better cosmetic results.18 During the incision, an Allis clamp or skin hook is used to grasp and evert the base of the umbilicus, raising it from the abdominal structures.
Prior to entry, check the patency of the Veress needle by passing normal saline through the instrument. The surgeon should then palpate the abdominal aorta and sacral promontory. The patient must be positioned completely flat and the operating table is set as low as possible so as to maximize the surgeon’s upper body control during insertion of the Veress needle. Use of premature Trendelenburg alters the usual landmarks and can increase the risk of injury. A prospective study involving 97 women undergoing operative laparoscopy showed that the position of the aortic bifurcation is more likely to be caudal to the umbilicus in the Trendelenburg position, compared with the supine position, regardless of body mass index.19 The Veress needle, held at the shaft, is directed toward the sacral promontory. The surgeon and assistant apply counter traction by grasping the skin and fat on each side of the umbilicus with a towel clip.20
The needle should be inserted at approximately a 45-degree angle while the patient is horizontal. A 90-degree angle of insertion is recommended to avoid “tunneling” after adequate training with this technique. In obese patients, a 90-degree angle is necessary initially to enter the peritoneal cavity. By contrast, in thin individuals, vital structures are closer to the abdominal wall. In any entry, only a small portion of the veress needle or trocar is inserted into the peritoneal cavity; rarely more than 2 to 3 cm.
Verification of Intraperitoneal Entry
Hanging drop Method
Correct needle placement is verified by the “hanging drop” technique. A drop of saline is placed on the hub of the Veress needle after insertion through the abdominal wall; lifting the abdominal wall establishes negative pressure within the abdomen, drawing the drop of fluid into the needle. Absence of this sign indicates improper placement of the Veress needle.
The Syringe Test
A 10 ml syringe with normal saline is attached to the Veress needle and aspiration verifies the absence of bowel contents or blood. The saline is injected into the peritoneal cavity, and if the needle is placed correctly, the fluid cannot be withdrawn because it is dispersed intraperitoneally. If the needle is placed within adhesions or the preperitoneal space, the fluid usually is recovered by aspiration. If the needle has been placed in vasculature or in the intestine or bladder, characteristic contents are drawn back.
Once the Veress needle is inserted and low flow CO2 has been started, the intra-abdominal pressure should be no greater than 9 or 10 mmHg. If higher intra-abdominal pressures are encountered, the needle has been placed improperly. The tip can be lodged in the omentum and can be dislodged by gently elevating and shaking the lower abdominal wall. If this maneuver fails, the needle hub is manipulated in a different direction because the anterior abdominal wall could block its distal hole. If neither of these techniques relieves the increased recorded pressure, the Veress needle is removed and reinserted. Occasionally, while it is passing through the different layers of the abdomen, tissue lodges in the tip, obstructing the opening. Whenever the Veress needle is withdrawn because of high-recorded pressures, the surgeon should check its patency.
Alternative Sites for Entry
Different laparoscopic entry sites may be used in patients who have had multiple previous laparotomies. One alternative entry site is the left sub costal margin in the midclavicular line. Before entry, the site is palpated and per cussed to rule out splenomegaly or an insufflated stomach from a misplaced endotracheal tube.
In patients who have developed preperitoneal emphysema from unsuccessful attempts to enter at the umbilicus or other abdominal sites the surgeon can attempt entry using a transvaginal approach. If there is no evidence of pelvic thickening or masses in the cul-de-sac and if the uterus is mobile, entry can be attempted through a small colpotomy.21
Alternatively, the surgeon can enter the abdomen using the uterus to protect the viscera.22, 23 The uterine fundus held against the abdominal wall using the uterine manipulator. A needle is passed through all layers of the abdomen and into the uterine fundus. As the uterus is pulled away from the tip of the needle, intra-abdominal placement is achieved. Similarly, the Veress needle can be inserted transcervically through the uterine fundus and into the abdominal cavity. Importantly, these alternative methods have uncertain margins of safety. Puncture of the uterus with this technique may result in persistent low-grade bleeding throughout the laparoscopy. Inadvertent perforation of the bladder or the broad ligament can result in hemorrhage. Intrauterine or intramyometrial positioning of the Veress during insufflation may result in gas embolism. These techniques are contraindicated if fundal adhesions are anticipated or if chromopertubation is necessary.24
In an obese patient, proper placement of the Veress needle may be difficult to achieve. If the Veress “tunnels” below instead of within the umbilicus, the surgeon may encounter preperitoneal emphysema. To avoid this complication, it is preferable to insert the needle and trocar transumbilically at 90 degrees, using towel clips for traction and abdominal wall elevation.25
A survey of existing data on the rates of failure and complications for each of the available methods of creating pneumoperitoneum showed that no technique was superior. Laparoscopic surgeons should be familiar with all these techniques.26
Once the surgeon is confident about the proper position of the Veress needle, high flow CO2 can be used. After 1 liter of CO2 is insufflated, the surgeon should percuss the right costal margin to check for loss of liver dullness. If liver dullness persists, the surgeon should assume the Veress needle is positioned improperly and should attempt entry again. Although traditionally adequate pneumoperitoneum had been defined by arbitrary volumes of CO2, the surgeon should instead rely on palpable abdominal distention and the intra-abdominal pressure reading as this will more accurately reflect the adequacy of the pneumoperitoneum.
Once correct intraperitoneal placement of the Veress needle is assured and pneumoperitoneum is established, primary trocar related injuries can be avoided by mapping the abdomen before insertion. To map the abdomen, use an 18 or 21-gauge spinal needle attached to a syringe partially filled with saline while maintaining pneumoperitoneum with low flow CO2 insufflation through the Veress. The spinal needle is inserted into the peritoneal cavity transumbilically or at another proposed location for entry at several points. If the needle is placed in an area free of viscera or adhesions, upon aspiration bubbles of CO2 gas will rise in the fluid filled syringe.
Placement of the primary trocar
The trocar should be inserted at a 90-degree angle to the abdominal wall and directed toward the sacral promontory. The major anatomic landmarks include the sacral promontory; the umbilicus, located at the level of L3 and L4; and the abdominal aorta which bifurcates between L4 and L5. Control of the laparoscopic trocar is essential as it penetrates each layer of the anterior abdominal wall. The trocar is inserted with the patient in a horizontal position because viscera tend to slide away from the advancing trocar. A premature Trendelenburg position does not prevent visceral injury, even if significant adhesions are present. Instead, altering the patient’s position affects the surgeon’s appreciation of important landmarks increasing the risk of injury.
Recent studies measuring the thickness of the abdominal wall at the umbilicus favor a vertical orientation and insertion through its base while elevating the periumbilical skin with towel clips.27 As omental and bowel adhesions to the anterior abdominal wall are often seen extending inferiorly from the umbilicus following pelvic surgery, orientation of the trocar at 45 degrees will direct the instrument into this area. By contrast, a perpendicular orientation may result in entry cephalad to the adhesions. Performed with care, a controlled entry in this fashion will prevent injury to the great vessels at the level of the sacral promontory.
Soderstrom and Butler noted a 10-fold reduction in the complication rate when a consistent operating format was used.28 Successful insertion depends on an adequate skin incision, trocars in good working condition (disposable trocars should be checked to be sure they are not locked), proper orientation of the trocar, the sheath, and the surgeon’s hand, as well as control over the instrument’s force and depth of insertion.
The surgeon should position the patient in a supine position at the height of the surgeon’s waist or slightly below it. The surgeon should palm the trocar with the dominant hand with the index finger extended to the level of the maximal planned penetration to prevent excessive depth upon insertion. As the trocar is advanced with firm downward pressure, the surgeon will sense when the fascia is traversed and should then reduce the force used and advance more slowly into the peritoneum. Although disposable bullet-tip trocars cannot prevent injury entirely, 29 they are preferable. A disposable shielded trocar has two advantages: a safety shield that snaps into position after the peritoneum is entered and a sharp instrument for each operation.
Trocar insertion without creating a pneumoperitoneum decreases operating time and may prevent potential complications. Direct insertion is a safe alternative to initially creating a pneumoperitoneum.30-37 Nezhat et al compared the ease and safety of creating a pneumoperitoneum with direct insertion using either a reusable trocar or a disposable shielded trocar in 200 patients in a randomized, prospectively controlled study.30 Complications rates of 22%, 6%, and 0%, respectively, were observed. Although there were fewer complications using direct insertion, no differences were noted in the ease of insertion or the frequency of multiple attempts.
The abdominal wall is elevated with towel clips applied close to the umbilicus. After the trocar is inserted into the peritoneal cavity, the laparoscope is introduced to verify its correct intraperitoneal placement. A pneumoperitoneum is then created with high flow insufflation. At some of our centers, we preferentially use direct trocar insertion, except in patients who have had multiple laparotomies. Since 1989, more than 4500 direct trocar insertions have been performed without major complications.
In a randomized comparison of Veress needle and direct trocar insertion, Byron and Markenson reported no major complications with either technique. Complications such as preperitoneal insufflation, failed entry, and needing more than three attempts to enter the peritoneal cavity were more common (P<0.05) in the Veress needle group. Additionally, the mean operative times using the direct insertion and Veress needle techniques were 15.3 and 19.6 minutes (P<0.01), respectively, in 113 patients who underwent sterilization procedures.
Optical Trocar Insertion
Optical trocars are single use hollow trocars that accommodate a zero degree laparoscope and allow real-time monitor images while transecting abdominal wall layers. Multiple systems are available on the market. However, any advantage to visual entry has not been fully explored in randomized trials. These trocars have not been shown to avoid visceral or vascular injury. Moreover, some of these systems require that the surgeon exert significant force to transect abdominal wall layers but with no means to easily avoid excessive depth of penetration.12
In 1971, Hasson introduced the concept of open laparoscopy to eliminate the risks associated with insertion of the Veress needle and trocar.38 This technique involves direct trocar insertion through a small skin incision without prior pneumoperitoneum. Specially designed equipment includes a cannula and trumpet valve fitted with a cone-shaped stainless steel sleeve. A blunt obturator protrudes 1cm from the tip of the cannula. The cone sleeve seals the peritoneal and fascial gap.
A small transverse, curved, or vertical incision is made at the umbilicus. As the incision is made, Allis clamps or a self-retaining retractor can be used to provide adequate exposure. Once the fascia is cut, a 1-cm incision is made in the peritoneum. The peritoneal edge and fascia are tagged with 0 polydioxanone (Ethicon). The corklike cannula carrying the blunt obturator is inserted through the opening into the peritoneal cavity. The obturator is withdrawn, and CO2 is insufflated through the cannula, which is inserted as deep as required to prevent leakage. The previously placed sutures are used to fix the trocar sleeve so that the laparoscope can move freely within the abdominal cavity. At the end of the procedure, the abdominal wall is closed, using the previously placed sutures.
Open laparoscopy usually takes 5 to 10 minutes longer than closed laparoscopy done by operators with comparable expertise. In more than 1000 consecutive operations done by Hasson, the frequency of minor wound infection was 0.6% and that of small bowel injury was 0.1%. In a review of the open technique, it was found to reduce the incidence of failed procedures, inappropriate gas insufflation, gas embolism, bladder and pelvic kidney punctures, major vessel injuries, and postoperative herniations.39
In a survey conducted by Penfield, intestinal laceration was the most serious complication of open laparoscopy, and most of those lacerations occurred during the early use of this technique.40 In 10,840 open laparoscopies attempted by 18 board-certified obstetrician/gynecologists, six bowel lacerations were reported, four were recognized and repaired, and two were not suspected until several days postoperatively.
To reduce the risk of bowel laceration, the surgeon should use a focus spotlight, work with an experienced assistant, make a vertical incision to facilitate exposure, grasp and elevate the fascia with small Kocher clamps, and cut between the clamps. A gynecologist who attempts open laparoscopy only in special situations will find that the procedure is slow and cumbersome because of difficulty in exposing and identifying each layer of the abdominal wall.
Placement of additional cannulas depends on the patient’s anatomy, the contemplated procedure and the surgeon’s preference. For diagnostic purposes, an incision generally is made 4 to 5 cm above the symphysis pubis in the midline. This area, delineated by the two umbilical ligaments and the bladder dome, is safe and usually avascular.
For operative laparoscopy, two accessory trocars (5 mm) are placed 4 to 5 cm above the symphysis pubis at the outer border of the rectus muscle, 3 to 4 cm below the iliac crest, and 2 to 3 cm lateral to the deep inferior epigastric vessels. These trocars are inserted under direct visualization to lessen the risk of intra-abdominal visceral, uterine, and vascular injury.
Two vessels provide blood supply to the lower abdomen: the deep inferior epigastric originating from the external iliac artery and the superficial epigastric, a branch of the femoral artery. Transillumination helps identify the superficial inferior epigastric, but this technique is limited in obese patients. The deep inferior epigastric vessels run lateral to the umbilical ligaments and are seen intraperitoneally and identified easily. These vessels pass in front of the round ligament, proceed to the anterior abdominal wall, and are seen above the peritoneum. To avoid injuring these vessels, the trocar is inserted medial or lateral to the umbilical ligaments by viewing the underside of the abdomen wall laparoscopically. Despite these precautions, aberrant vascular branches occasionally are traumatized, and the surgeon should be well versed in management of vascular injuries.
To reduce the chance of trauma to the abdominal structures, the proposed site for the secondary puncture is indented by applying abdominal pressure with the index finger and observing the peritoneal surface with the laparoscope. Mapping of the potential sites for accessory trocar placement can be achieved by advancing the tip of an 18-gauge or 21-gauge needle attached to a syringe transabdominally through the peritoneum, revealing the exact course and placement of the accessory trocar. An advantage of first inserting the 21-gauge needle is its small diameter, because the injury incurred does not require repair. As the needle’s placement is seen, there is little risk of missing a visceral injury. These maneuvers are especially important in patients with evidence of abdominal wall adhesions, and can help to ensure safe access.
The surgeon palms the trocar sheath to control the depth of penetration while it is inserted through the skin, fat, and fascia. Further advancement is controlled under a laparoscopic view. The trocar is aimed toward the center of the abdomen and hollow of the sacrum. If it is aimed laterally it can slide down the pelvic side wall without being seen through the laparoscope, resulting in injury to the iliac vessels. The accessory trocars should never be inserted without laparoscopic observation of their indentation on the abdominal wall or before mapping the abdomen. When insertion of the trocars is viewed directly from the monitor, the surgeon should be sure the camera has not been rotated showing the wrong view of the pelvis.
Some accessory trocar sleeves are too long to allow free access to the pelvic structures and tend to slip out of the peritoneal cavity. The presence of trap valves may interfere with efficient instrument exchange, may prevent the introduction and removal of suture material and may hinder removal of excised tissue. Several accessory trocar sleeves either screw in or have an umbrella to secure them to the abdominal wall. Radially expanding trocars may reduce laparoscopic complications and improve patient outcomes.41 Two hundred and twelve women underwent various laparoscopic procedures involving the placement of 541 radially expanding access cannulas, and no major complications occurred. One patient developed a postoperative mesenteric hematoma that was assumed to be secondary to a venous injury from the Veress needle. Despite the absence of fascial anchoring devices, only six cannulas(1%) slipped.
3 mm Accessory Trocars
Smaller trocars and instruments, originally developed for pediatric surgery, can be used to treat multiple pathologies laparoscopically. We have successfully performed endometrioma excision, salpingectomy, ovariolysis, appendectomy and simple ovarian cystectomy using 3 mm trocars and instruments. Further prospective study is warranted to fully assess the potential benefits of using the 3 mm trocars and instruments; however there is potential for post-operative pain reduction, reduced incidence of herniation and increased cosmesis.
The number of accessory trocar sites needed is determined by the pathology encountered on diagnostic laparoscopy, the planned procedure and surgeon preference. Examples of procedures necessitating a single accessory site include tubal sterilization, aspiration of an ovarian cyst, and mild peritubal and periovarian adhesiolysis. Two accessory sites are suggested for lysing peritubal and peri-ovarian adhesions, salpingectomy, ectopic pregnancy, or excision of moderate pelvic endometriosis. For procedures requiring traction, hemostasis and suturing three sites may be necessary. Examples include salpingo-oophorectomy, hysterectomy, repair of an ovarian or uterine incisional defect, lysis of extensive abdominal or pelvic adhesions, myomectomy, and cystectomy.
Special Considerations in High Risk Patients
Special care is required during entry in obese patients because the trocar is inserted almost vertically. The distance between the sacral promontory and the trocar tip is relatively small, and there is a risk of injury to the major vessels. Similarly, in thin patients injury is also possible. The force required to introduce the trocar is less than anticipated because the fascia is thin and offers limited resistance.
In women who have had previous laparotomies, the intra-abdominal anatomy may be altered by adhesive disease. Inflexible adhesive bridging between the intestine and the abdominal wall can nullify any protection from trocar injury afforded by elevating the abdominal wall, creating a pneumoperitoneum, using the Trendelenburg position, and maintaining intestinal mobility. In some patients, injury will occur to adherent omental vessels or directly to the bowel wall. The patients at the highest risk are those who have undergone major abdominal surgery (such as bowel resection) or an exploratory laparotomy for abdominal trauma or ovarian carcinoma.20
The association between intestinal and omental adhesions and injury to those structures during operative laparoscopy was evaluated in 360 patients who previously had undergone a variety of abdominal operations.42
The following findings are of note:
1. Patients with prior midline incisions have more adhesions than do those with prior Pfannenstiel incisions.
2. Patients with multiple prior incisions do not have more adhesions than do those with a single prior incision.
3. Women with prior midline or Pfannenstiel incisions for gynecologic operations have more adhesions than do those who have undergone obstetric operations.
4. Patients with prior midline incisions for obstetric operations do not have more adhesions than do those with a prior Pfannenstiel incision for obstetric operations.
The following conditions were associated with severe adhesions:
1. Generalized peritonitis
2. Bowel resection after intestinal obstruction
3. Oncologic procedure with omentectomy
4. Previous radiation and intraperitoneal chemotherapy
5. Previous adhesions
In these 360 patients, intestinal injuries occurred during entry in 21 instances. Of these injuries, six were to the small bowel. Only one patient had a single incision; the remaining five had multiple incisions and complicated surgical histories. Two small bowel injuries occurred during open laparoscopy. In these two patients, the small bowel was attached to the anterior abdominal wall, directly under the umbilicus. It was entered during incision of the fascia that was attached to the intestine. With the exception of 32 patients in whom open laparoscopy was done, the closed technique with prior establishment of pneumoperitoneum was used. The use of open laparoscopy was based on the patients’ surgical history (bowel resection, bowel obstruction, ovarian cancer surgery) and the surgeons’ preoperative judgment.
Attachment of the bowel and omentum to the abdominal wall usually occurs distal to the umbilicus. If the insertion of the trocar is more vertical than oblique, the possibility of bowel injury is less especially if a disposable trocar with a shield is used. However, in patients who have had complicated abdominal operations (bowel resection, bowel obstruction, etc.), the bowel may be attached under, very close to, or occasionally above the umbilicus.
In a subsequent study, the safety of direct trocar insertion was evaluated in 246 consecutive women with previous uncomplicated Pfannensteil or midline incisions. All of them underwent bowel preparation and understood that laparotomy was possible. Trocar insertion was almost at a 90-degree angle while the operator and the assistant elevated the abdominal wall, lateral to the umbilicus. Fifty patients had omental adhesions, and 34 had bowel adhesions to the anterior abdominal wall. There were no small bowel injuries. There were five omental injuries; in one, the injury was associated with bleeding and was managed laparoscopically.
On the basis of these studies, it can be concluded that the incidence of subumbilical bowel adhesions and subsequent bowel injury is most likely related to the indication and approach for the previous laparotomy rather than to the type or number of previous laparotomies. The incidence of bowel injuries during insertion of the primary trocar is low. The closed technique with or without prior establishment of a pneumoperitoneum can be used in most instances without an increased risk of bowel injury.
Several procedures have been described to assess the anterior abdominal wall for intestinal adhesions. DeCherney advocates using a small-gauge needle laparoscope 2 to 3 mm in diameter.43 The needle scope is inserted instead of the Veress needle under direct vision through the umbilical, preperitoneal, and subperitoneal structures. The Veress needle is inserted intra-abdominally, and insufflation proceeds under direct observation.
Alternatively, we advocate that the surgeon explore the periumbilical area with an 18-gauge needle attached to a syringe after establishing the pneumoperitoneum. If adhesions are detected by these techniques, the options include open laparoscopy or alternative sites for abdominal entry. The primary trocar can be inserted at multiple possible alternative sites but care must be taken to remain at least 5 cm below the xiphoid and 5 cm above the pubic symphysis.28 Although the techniques described can help detect periumbilical adhesions, they are not definitive and are time consuming. Based on these observations, we recommend that the surgeon assess each patient’s surgical history and judge the need for these procedures based on potential risk for bowel injury. The surgeon should keep in mind the continuum of risk in that patients with a simple history of prior Pfannensteil are much less likely to have adhesions involving the umbilicus as compared to those with a history of multiple abdominal surgeries involving midline incisions especially those that cross above the umbilicus.42
After insertion of the trocars, the intra-abdominal pressure should be preset between 12 and 16 mmHg during the operative procedure. Higher pressures for long periods may cause subcutaneous emphysema or put the patient at risk for gas emboli.
Operative laparoscopy enables a physician to do complex, delicate procedures through small incisions, thus decreasing the patient’s discomfort, morbidity, expense, and duration of convalescence.44 Laparoscopy is a technique for assessing the extent of pathology and gives the surgeon an opportunity to remove abnormal tissue and reconstruct damaged organs. To become proficient with operative laparoscopy, a gynecologist must understand the inherent learning curve and begin with simple procedures before gradually advancing to more complicated ones. Key to any successful laparoscopic procedure is safe abdominal access. Several techniques, instruments and approaches to minimize the risk of injury have been introduced and reviewed here. Every laparoscopic surgeon should be familiar with multiple entry techniques and alternatives. Perhaps more importantly, however, a competent laparoscopic surgeon should be able to quickly recognize and address injuries when they do occur.
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