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LAPAROSCOPIC ENTRY
1.
© Royal College
of Obstetricians and Gynaecologists LAPAROSCOPIC ENTRY GREEN-TOP GUIDELINE, 2008 SOGC CLINICAL PRACTICE GUIDELINE, 2013 Aboubakr Elnashar Aboubakr Elnashar
2.
© Royal College
of Obstetricians and Gynaecologists CONTENTS 1. POSITION OF PATIENT 2. PRIMARY PORT CLOSED ENTRY 3. SECONDARY PORT ENTRY 4. PRIMARY PORT ALTERNATIVES 5. EXIT TECHNIQUES Aboubakr Elnashar
3.
© Royal College
of Obstetricians and Gynaecologists 1. POSITION Prone Stirrups/Lloyd Davis Non slip mattress Trendelenberg after ports Aboubakr Elnashar
4.
© Royal College
of Obstetricians and Gynaecologists 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
5.
© Royal College
of Obstetricians and Gynaecologists Why intra umbilical entry? Fixed peritoneum Thin Least vascular Cosmetic 2. PRIMARY PORT CLOSED ENTRY Aboubakr Elnashar
6.
© Royal College
of Obstetricians and Gynaecologists 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
7.
© Royal College
of Obstetricians and Gynaecologists Insertion of Veress needle Pencil grip Vertical, then towards pelvis Double “click” Aboubakr Elnashar
8.
© Royal College
of Obstetricians and Gynaecologists Far lateral Incorrect Incorrect Correct Midsagittal Plane Insertion Aboubakr Elnashar
9.
© Royal College
of Obstetricians and Gynaecologists • 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
10.
© Royal College
of Obstetricians and Gynaecologists • 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
11.
© Royal College
of Obstetricians and Gynaecologists Saline test Withdraw Instil Withdraw If no fluid, frank blood (or faeces) then proceed with insufflation Aboubakr Elnashar
12.
© Royal College
of Obstetricians and Gynaecologists • 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
13.
© Royal College
of Obstetricians and Gynaecologists 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
14.
© Royal College
of Obstetricians and Gynaecologists 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
15.
© Royal College
of Obstetricians and Gynaecologists The greater the gas bubble & abdominal wall tension the less the risk of bowel injury Abdominal pressure= 8mmHg Abdominal pressure=25mmHg Aboubakr Elnashar
16.
© Royal College
of Obstetricians and Gynaecologists 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
17.
© Royal College
of Obstetricians and Gynaecologists • 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
18.
© Royal College
of Obstetricians and Gynaecologists 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
19.
© Royal College
of Obstetricians and Gynaecologists • 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
20.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
21.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
22.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
23.
© Royal College
of Obstetricians and Gynaecologists Primary Trocar Non VISUAL ENTRY SYSTEMS Conventional trocar and cannula HASSONVersa Step RADIALLY EXPANDING Disposable Shielded Trocars Aboubakr Elnashar
24.
© Royal College
of Obstetricians and Gynaecologists Commonest problem - failed entry Insertion of subumbilical Veress needle Aboubakr Elnashar
25.
© Royal College
of Obstetricians and Gynaecologists 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
26.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
27.
© Royal College
of Obstetricians and Gynaecologists Closed entry can still cause bowel injury, especially if adhesions are present Aboubakr Elnashar
28.
© Royal College
of Obstetricians and Gynaecologists Other injuries – Vascular injury – Retroperitoneal haemorrhage – Bladder injury – Injury to over inflated stomach Aboubakr Elnashar
29.
© Royal College
of Obstetricians and Gynaecologists 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
30.
© Royal College
of Obstetricians and Gynaecologists • 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
31.
© Royal College
of Obstetricians and Gynaecologists Round ligament Obliterated umbilical artery Rectus muscles Mid-line Aboubakr Elnashar
32.
© Royal College
of Obstetricians and Gynaecologists Inf epigastric artery Aboubakr Elnashar
33.
© Royal College
of Obstetricians and Gynaecologists 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
34.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
35.
© Royal College
of Obstetricians and Gynaecologists 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
36.
© Royal College
of Obstetricians and Gynaecologists Aboubakr Elnashar
37.
© Royal College
of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists Trans cul-de-sac Trans uterine Other Sites Of Insertion Trans cul-de-sac or Trans uterine Aboubakr Elnashar
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of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists Disposable shielded (safety) trocars They were intended to prevent the sharp tip from injuring intra-abdominal contents. Aboubakr Elnashar
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of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists Versa Step 3-5 Radially expanding access system Expanding polymeric sleeve. Aboubakr Elnashar
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of Obstetricians and Gynaecologists Primary trocar Visual entry systems Endo TIP VisiPort Optiview Disposable Reusable Aboubakr Elnashar
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of Obstetricians and Gynaecologists Under direct view to identify: Bleeding Injury to omentum Injury to bowel - (partial/complete) 5. EXIT TECHNIQUES Aboubakr Elnashar
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of Obstetricians and Gynaecologists • 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
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of Obstetricians and Gynaecologists 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
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of Obstetricians and Gynaecologists Fig. 1. Incision through the skin of the umbilicus. Allis clamps applied on both sides of the umbilicus Aboubakr Elnashar
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of Obstetricians and Gynaecologists Fig. 2. Incision through the fascia and peritoneum. Kocher clamps applied on the fascia Aboubakr Elnashar
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of Obstetricians and Gynaecologists Fig. 3. Metzembaum scissors in the abdominal cavity to confirm successful entry Aboubakr Elnashar
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of Obstetricians and Gynaecologists Fig. 4. Suture (2-0 Vicryl on UR6 needle) placed in the fascia Aboubakr Elnashar
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of Obstetricians and Gynaecologists Fig. 5. Hasson port (Ethicon Xcel) placed in the abdomen Aboubakr Elnashar
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of Obstetricians and Gynaecologists Fig. 6. Port secured with the suture Aboubakr Elnashar
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of Obstetricians and Gynaecologists Aboubakr Elnashar