Laparoscopic surgery

1. COMPARATIVE STUDY OF TRANS-UMBILICAL AND
INFRA-UMBILICAL PORT INSERTION IN LAPROSCOPIC
SURGERIES
Dr. Sunil Kumar
Department of General Surgery
Guru Gobind Singh Medical College
and Hospital, Faridkot

2. Particulars of Guide and Co Guide
• Guide: Dr. Amandeep Singh
Associate professor
Incharge Unit 4
Department of General Surgery
• Co Guide: Dr. Sarabjeet Singh
Professor
Incharge Unit 3
Department of General Surgery

3. Aims and Objectives
To compare transumblical and infraumbilical port insertion in
regards to
• Ease of entry and duration for successful start of
pneumoperitoneum.
• Various complications like port site pain, port site infection,
port site hernia.
• Cosmetic outcomes.

4. Purpose of Study
• In the modern era of medical science, laparoscopic surgeries are well
preferred over the open surgeries .
• The whole purpose of Minimal Access surgery is to achieve utmost
cosmesis, less hospital stay time, minimal scaring, less post operative pain.
• The most critical and dangerous step in laparoscopy is safe and successful
insertion of primary port without causing intrabdominal injuries.
• Initially common first port site entry is either through infraumbilicus or
supraumbilicus. Now transumbilical insertion is also advocated.
• Due to the anatomy of abdomen at umbilicus, technical advantages are
comparative ease, less force, comparative bloodless, invisible scar.
• So this study has been planned to compare transumbilical and infraumbilical
port insertion in laparoscopic surgeries in regards to ease of entry, duration
for successful start of pneumoperitoneum, port site complications and
cosmetic outcomes.

5. Material & Methods
I. Study setting: This study will be conducted in the
Department of General Surgery, Guru Gobind Singh
Medical College & Hospital Faridkot after approval from
institutional ethical committee.
II. Study period: 18 months.
III. Study Design: Comparative study.
IV. Study Population: All the patients presented to
outpatient and admitted under the department of
general surgery or urology department undergoing
laparoscopic surgery for any aetiology.

6. Material & Methods
Inclusion Criteria
• Patients with age 18-60
years and of either sex.
• Patients giving consent for
laparoscopic surgery.
Exclusion Criteria
• Patients with age less than 18 years and
more than 60 years.
• Patient with immuno-compromised
status.
• Patients with co-morbid factors like
diabetes, cardiac disease, respiratory
disease, organ failure were excluded.
• Patients with previous midline
laparotomy.
• Patients with umbilical conditions like
umbilical hernia, infection, scar.
• Patient with coagulopathy.
• Patient requiring more than 3 attempts
by either approach.
• Morbid obese patients.
• Pregnancy.
• Ascites and portal hypertension.

7. Material & Methods
V. SAMPLE SIZE: On the basis of 5% level of significance and 80%
power of test, the optimal sample size is 80. Patients are selected
according to the inclusion and exclusion criteria.
VI. Sampling Technique: Keeping in view of the availability and
feasibility of the participants, a non-random convenient sampling
technique will be adopted. So, consecutively 80 eligible participants
will be considered for the study.
VII. Data Collection Tools: The data will be collected using a pre-
designed structured performa eliciting information regarding socio-
demographic and other clinical variables. (Performa attached with
the plan).
• .

8. Methodology
All the patients will be worked up and assessed according to following
principles:
1)Detailed history .
2)Complete clinical examination.
3)Complete routine investigations.
Pre operative:
• Shaving will be done at the operative area.
• All patients will be given Inj Ceftriaxone 1gm iv stat 1hour before surgery.
• Umbilicus will be cleaned with spirit and 10% Povidone iodine sol.
• All the patients are explained about the procedure. Group allocation will be
done by envelop method. 80 no. of such sealed envelops with label T
(transumbilicus) and I (Infraumbilicus) will be kept in OT. Envelop will be
picked by some staff in the OT randomly and the approach of port insertion
will be selected accordingly.
Group A (patients undergoing transumbilical port insertion) = 40
Group B (patients undergoing infraumbilical port insertion) = 40

9. Intra Operative:
All the patients in the study will be administered general anesthesia and
placed in supine position.
In Group A:
• After meticulously cleaning of umbilicus, umbilicus will be lifted up and the
central axle/apex of umbilicus will be excised vertically with blade no. 11
after retracting the umbilical fold.
• The anterior abdominal wall will be lifted both above and below the
umbilicus.
• 10mm port will be inserted blindly and location will be confirmed visually
using laparoscope and pneumoperitoneum will be done.
• All other ports will be inserted under direct vision.
• At the end of procedure umbilicus will be irrigated with normal saline and
closed with interrupted sutures ( no. 0 vicryl) in subcuticular fashion.
In Group B:
• Infra-umbilical incision will be given horizontally.
• Subcutaneous fat dissection will be done and umbilical pillars will be
visualized.
• Vertical incision will be given at the junction of umbilical pillar and sheath.
• Port will be inserted through the incision.

10. Following parameters will be evaluated :
• Time taken from incision to camera port insertion with successful
creation of pneumoperitoneum.
• Bleeding from port site.
• Number of attempts to enter peritoneum, loss of port,
subcutaneous emphysema, gas leak from port site.
Post Operative:
• Daily antiseptic dressing will be done.
• Post Op analgesic will be given 8 hourly.
• Pain score using visual analogue scale, measured on follow up.
• Patients will be followed up weekly for delayed complications.
Data analysis plan
After completion of the study, observations obtained will be
tabulated, analyzed and evaluated using statistical methods.
Appropriate statistical techniques will be used to compare the two
groups. Data will be described by using means and standard
deviation

11. References
• Spancer SJ, Warnock GL. A brief history of endoscopy, laparoscopy, and
laparoscopic surgery. J laparoendosc Adv Surg Tech A.1997;7(6):369-373.
• Senturk MB, Dogan O, Polat M, Kilicci C, Pulatoglu C, Tayyar AT. Cosmetic outcomes
of infraumbilical, supraumbilical, and transumbilical entry routes in laparoscopic
surgery. Turk J Surg. 2018;34(4):290-294.
• Toro A, Mannino M, Cappello G, Di Stefano D, Di Carlo I. Comparison of two entry
methods for laparoscopic port entry: Technical point of view. Diagnostic and
therapeutic endoscopy. 2012;2012:1-7.
• Maharaul HH, Jain N, Garg P. Port site complications following laparoscopic
surgeries. IJSS. 2019;3(3):318-324.
• Wani A, Dalal AK, Dalal UR, Rathi H, komal, Garg A. Comparative evaluation of
transumbilical and infraumbilical 5mm blind trocar insertion for camera port in
laparoscopic cholecystectomy. J. Evid. Based Med. Healthc. 2019; 6(18), 1383-1387.
• Mudgal MM, Kothiya PK, Kushwah N, Singh R. Port site complications following
laparoscopic surgeries: a prospective study. Int Surg J. 2018;5(2):598-601.
• Karthik S, Augustine AJ, Shibumon MM, Pai MV. Analysis of laparoscopic port site
complications: A descriptive study. J Minim Access Surg. 2013;9(2):59-64.
• Resutra R, Mahajan N, Gupta R. Transumbilical first trocar access during
laparoscopic surgery. Int J Res Med Sci. 2019;7(8):3039-3043.

12. Patient Performa
• S.No. C.R.No.
• Name Age and Sex
• Father’s/Husband’s name
• Occupation
• Address
• Date of admission
• Date of operation
• Date of discharge
• Previous history of any disease
• Investigations
Haemoglobin
B.T/C.T
PTI/INR
T.L.C
Platelets
Blood urea
Serum creatinine
Viral markers
Fasting blood sugar
X-ray chest
ECG
• Surgical technique
• Operative findings
• Duration of operation and ease in surgery
• Cost of operation
• Post-operative pain score 1 hr. 6 hr. 12 hr. 24 hr.
• Immediate post op complication
Infection
Seroma
Haematoma
Pain
• Date of discharge
• Total hospital stay
• Follow up:
1 week 4 weeks 8 weeks
Port site Infection
Pain
Scar
Hernia
Granuloma
cosmetic result