LAPAROSCOPIC ENTRY

© Royal College of Obstetricians and Gynaecologists

LAPAROSCOPIC ENTRY

GREEN-TOP GUIDELINE, 2008

SOGC CLINICAL PRACTICE GUIDELINE, 2013

Aboubakr Elnashar

Aboubakr Elnashar


CONTENTS

1. POSITION OF PATIENT

2. PRIMARY PORT CLOSED ENTRY

3. SECONDARY PORT ENTRY

4. PRIMARY PORT ALTERNATIVES

5. EXIT TECHNIQUES

Aboubakr Elnashar


1. POSITION

Prone

Stirrups/Lloyd Davis

Non slip mattress

Trendelenberg after ports

Aboubakr Elnashar


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

Aboubakr Elnashar


Why intra umbilical entry?

Fixed peritoneum

Thin

Least vascular

Cosmetic

2. PRIMARY PORT CLOSED ENTRY

Aboubakr Elnashar


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.

Aboubakr Elnashar


Insertion of Veress needle

Pencil grip

Vertical, then towards pelvis

Double “click”

Aboubakr Elnashar


Far lateral

Incorrect Incorrect Correct

Midsagittal Plane Insertion

Aboubakr Elnashar


• 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

• 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. (II-2 B)

• 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. (II-2 B)

Aboubakr Elnashar


• 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

• 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. (II-1 A)

Aboubakr Elnashar


Saline test

Withdraw

Instil

Withdraw

If no fluid, frank blood (or faeces) then proceed with insufflation

Aboubakr Elnashar


• The saline test not 100% accurate

• 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

Aboubakr Elnashar


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

• The Veress intraperitoneal (VIP-pressure 10mmHg) 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.

(II-1 A)

• After 2 failed attempts to insert the Veress needle,

either the open Hasson technique or Palmer’s point

entry should be used.

Aboubakr Elnashar


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)

Aboubakr Elnashar


The greater the gas bubble & abdominal wall tension the less the risk of bowel injury

Abdominal pressure= 8mmHg Abdominal pressure=25mmHg

Aboubakr Elnashar


3 kg force

3 kg force

25 mm Hg 15 mm Hg

The tip of the

trocar touched

abd contents

> 4 cm maintained. the

tip of the trocar never

touched abdominal

contents.

Trocar insertion

requires 4 to 6 kg of

force

> 4

cm

The high Pressure Entry

25-30 mmHg

Aboubakr Elnashar

http://medpics.findlaw.com/enlargeexhibit.php?ID=18073


• An intra-abdominal pressure of 20–25 mmHg

should be achieved before inserting the primary

trocar

• 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. (II-1

A)

Aboubakr Elnashar


The distension pressure should be reduced to

12–15 mmHg once the insertion of the trocars

is complete

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. (II-1 A)

Aboubakr Elnashar


• 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

Aboubakr Elnashar


Aboubakr Elnashar


Aboubakr Elnashar


Aboubakr Elnashar


Primary Trocar Non VISUAL ENTRY SYSTEMS

Conventional

trocar and cannula

HASSON Versa

Step

RADIALLY

EXPANDING

Disposable

Shielded

Trocars

Aboubakr Elnashar


Commonest problem - failed entry

Insertion of subumbilical Veress needle

Aboubakr Elnashar


Trocar Placement for Surgery

A: 12mm optical trocar placed at umbilical level

B and C: 5mm lateral operative trocars placed 3

fingerbreadths above the symphysis pubis

Aboubakr Elnashar


Aboubakr Elnashar


Closed entry can still cause bowel injury, especially if adhesions are present

Aboubakr Elnashar


Other injuries

– Vascular injury

– Retroperitoneal haemorrhage

– Bladder injury

– Injury to over inflated stomach

Aboubakr Elnashar


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

3. SECONDARY PORTS

Aboubakr Elnashar


• 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

Aboubakr Elnashar


Round ligament

Obliterated umbilical artery

Rectus muscles

Mid-line

Aboubakr Elnashar


Inf epigastric artery

Aboubakr Elnashar


The first laparoscopy picture above shows the left

inferior epigastric vessels and the site selected for the

insertion of the trocar.

The second picture shows the trocar being inserted

safely lateral to the vessels.

Aboubakr Elnashar


Aboubakr Elnashar


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

4. PRIMARY PORT –ALTERNATIVES

Aboubakr Elnashar


Aboubakr Elnashar


Palmer’s point is the preferred alternative trocar

insertion site, except in cases of previous surgery

in this area or splenomegaly.

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. (II-2 A)

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. (I-A)

Aboubakr Elnashar

© Royal College of Obstetricians and Gynaecologists Trans cul-de-sac Trans uterine

Other Sites Of Insertion Trans cul-de-sac or Trans uterine

Aboubakr Elnashar


When Hasson open laparoscopic entry is employed,

confirm that the peritoneum has been opened by

visualising bowel or omentum

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. (II-2 C)

Aboubakr Elnashar


Direct insertion of the trocar without prior

pneumoperitoneum may be considered as a safe

alternative to Veress needle technique. (II-2)

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. (I)

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. (II-B)

Aboubakr Elnashar


Disposable shielded (safety) trocars

They were intended to prevent the sharp tip from injuring

intra-abdominal contents.

Aboubakr Elnashar


Disposable shielded (safety) trocars

As it encounters resistance through the abdominal

wall, The shield partially retracts and exposes the

sharp tip

As the shield enters the abdominal

cavity, it springs forward and covers

the sharp tip of the trocar.

But There is a brief moment of contact

Aboubakr Elnashar


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. (I-

A)

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. (2 B) Aboubakr Elnashar


Versa Step

3-5

Radially expanding access

system

Expanding polymeric sleeve.

Aboubakr Elnashar


Primary trocar

Visual entry systems

Endo TIP

VisiPort Optiview

Disposable

Reusable

Aboubakr Elnashar


Under direct view to identify:

Bleeding

Injury to omentum

Injury to bowel

- (partial/complete)

5. EXIT TECHNIQUES

Aboubakr Elnashar


• 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.

Aboubakr Elnashar


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

Aboubakr Elnashar


Fig. 1. Incision through the skin of the umbilicus. Allis

clamps applied on both sides of the umbilicus

Aboubakr Elnashar


Fig. 2. Incision through the fascia and peritoneum.

Kocher clamps applied on the fascia

Aboubakr Elnashar


Fig. 3. Metzembaum scissors in the abdominal cavity

to confirm successful entry Aboubakr Elnashar


Fig. 4. Suture (2-0 Vicryl on UR6 needle) placed in

the fascia

Aboubakr Elnashar


Fig. 5. Hasson port (Ethicon Xcel) placed in the

abdomen

Aboubakr Elnashar


Fig. 6. Port secured with the suture

Aboubakr Elnashar


Aboubakr Elnashar

Health & Medicine

LAPAROSCOPIC ENTRY