Presented at multiple events

1. Ayman Ewies 1
Safe Laparoscopic Techniques
Ayman Ewies
Consultant Gynaecologist
SWBH
5 April 2019
28/09/2020

2. Ayman Ewies 2
Safe Laparoscopic Techniques
RCOG, GTG 49, 2008 – Preventing entry-related gynaecological laparoscopic injuries
Ayman Ewies
Consultant Gynaecologist
Sandwell & West Birmingham Hospitals NHS Trust
5 May 2017
28/09/2020

3. Ayman Ewies 3
How To Minimize Bowel Injury
In Laparoscopic Surgery?
Ayman Ewies
Consultant Gynaecologist
Sandwell & West Birmingham Hospitals NHS Trust
17 April 2013
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4. Ayman Ewies 4
References
1- A consensus document concerning laparoscopy entry
techniques: Middlesbrough Consensus, 19-20 March 1999.
2- Preventing entry-related gynaecological laparoscopic injuries:
RCOG, GTG 49, 2008
3- Principles of safe laparoscopic entry: ISGE taskforce, EJOGRB
2016; 201:179-188.
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Definition & Classification
of Complications
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Complications
o It is defined in the Oxford English Dictionary as:
a new problem or illness that makes treatment of a
previous one more complicated or difficult.
o Complications to laparoscopy are similar to side-effects
to medications:
while uncommon, both inevitably occur, often at the
least expected time and in the least expected
situation!
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Complications
o Complications will inevitably result from our
surgery no matter how experienced we are.
o There is a lot of truth in the old surgical aphorism
that “a surgeon who has no complications is
either a liar or has a very limited practice”.
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Complications - Classification
1. Phase 1 – Patient Identification
2. Phase II – Anaesthesia and Positioning
3. Phase III – Abdominal Entry and port placement
4. Phase IV – Surgery and exit techniques
5. Phase V – Postoperative recovery
6. Phase VI – Counselling
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Complications - Classification
1. Phase 1 – Patient Identification
2. Phase II – Positioning
3. Phase III – Abdominal Entry and port placement
4. Phase IV – Surgery
5. Phase V – Postoperative recovery
6. Phase VI – Counselling
Bowel injury may occur during the entry phase, the surgery phase or in
the postoperative phase!
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Complications – Classification of laparoscopic
entry-related injuries Middlesbrough Consensus
Type 1 injuries:
Damage by Veress needle or trocar to major vessels and
normally locate bowel.
Type 2 injuries:
Damage by Veress needle or trocar to bowel adherent to
the abdominal wall.
N.B. This may be inevitable whatever method of access is
selected: laparotomy v laparoscopy.
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Some Figures
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Incidence of Laparoscopy-Induced
Bowel Injuries
o This varies considerably between reports, depending
on the experience of the surgeons and the complexity
of the operations undertaken.
o Incidence:
✓ Finnish study (n= 70 607): 0.6/1000 (Harkki-Siren,
1997).
✓ Netherlands study (n=25 764): 1.13/1000 (Jansen,
1997).
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Incidence of Laparoscopy-Induced
Bowel Injuries
o van der Voort et al, 2004
✓ Diagnostic Laparoscopy: 0.06-0.5%
✓ Operative Laparoscopy: 0.3-0.5%
✓ Mortality rate : 3.6%
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Commonest sites
1. Small bowel: 60%
2. Colon: 32%
3. Stomach: 8%
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Timing
1. Recognized during surgery: 30-50%.
2. The remainder may represent anytime after surgery:
1. Traumatic injury presents early at 1-2 days.
2. Thermal injuries presents later at 4-10 days.
The later the diagnosis, the higher the mortality and
morbidity
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Mechanisms
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Mechanisms
1. During entry : 50%
2. Surgical trauma: the most common site is the
recto-sigmoid colon when dissecting
endometriosis in patients with advanced
disease.
3. Thermal injuries
4. Herniation through the port site: 0.06-1%
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Mechanisms – During Entry
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Mechanisms – During Entry
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Step by Step Guide
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Phase I – Patient Identification: Counselling & Consent
o It needs to be appreciated that even a diagnostic
laparoscopy can result in serious and life threatening
complications.
o “You told me this was just a quick look inside my tummy,
and look what’s happened”!
✓ Informed consent: risks and benefits.
✓ All the alternative choices.
✓ Use lay language e.g. removal of ovary not oophorectomy,
open surgery not laparotomy, etc.
✓ Information leaflet.
✓ Routine letter to patients as an additional safe guard to prevent
any misunderstanding.
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Phase I – Patient Identification: Characteristics
o Would you do a diagnostic laparoscopy for a woman with a past history
of a midline laparotomy for ruptured appendix who presents with pelvic
pain and an ultrasound scan showing fluid loculations that might
represent an ovarian cyst?
o RCOG Green Top Guidelines – 2008 (grade C evidence) -
Surgeons must be aware of the increased risks in:
✓ BMI > 35
✓ BMI < 18
✓ Previous midline abdominal incision
✓ Previous multiple abdominal surgeries
✓ Previous peritonitis
✓ Inflammatory bowel disease
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Phase I – Patient Identification: Bowel Preparation
o Oral bowel-cleansing agents have traditionally been used before
elective colo-rectal surgery to reduce the likelihood of complications
arising from anastomotic leakage.
✓ This practice is predominantly based on observational data and expert
opinion!
o However, there is an increasing body of evidence that bowel
preparation is not required for most procedures.
o Postoperative “enhanced recovery programmes” usually avoid
bowel preparation.
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Phase I – Patient Identification: Bowel Preparation
o Individualization is recommended according to the
planned surgery:
✓ No preparation: abdomino-perineal excision of the
rectum, right hemi-colectomy, total procto-colectomy or
an ileo-anal pouch operation.
✓ Preparation: anterior resection and left-sided
resections.
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Phase I – Patient Identification: Bowel Preparation
o Oral bowel-cleansing agents available in the UK:
1. Klen-Prep: Polyethylene glycol
2. Moviprep: Polyethylene glycol
3. Fleet Phospho-Soda: Sodium dihydrogen phosphate dehydrate and
disodium phosphate dodecahydrate
4. Picolax: Sodium picosulphate and magnesium citrate
5. Citrafleet: Sodium picosulphate and magnesium citrate
6. Citramag: Magensium carbonate and citric acid
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Phase II – Positioning
o The patient should be horizontal for insertion of the
primary trocar.
o The patient should be horizontal for insertion of the
primary trocar.
o The patient should be horizontal for insertion of the
primary trocar.
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Phase II – Positioning
GTG 49
o The operating table should be horizontal (not in the
Trendelenberg tilt) at the start of the procedure.
o The abdomen should be palpated to check for any
masses before insertion of the Veress needle.
Trendelenburg Position
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Phase II – Positioning
o The traditional practice of tilting the patient into a
steep 'head down' position serves to:
1. rotate the abdominal aorta into closer proximity to
the trocar tip!
2. displaces bowel from the pouch of Douglas into
the region of the umbilicus!
Trendelenburg Position
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Phase II – Positioning
o Prone
o Stirrups/Lloyd Davis
o Non slip mattress
Please empty the bladder !!
Trendelenburg Position
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Phase III – Abdominal Entry
Primary Port – GTG 49
o The primary incision for laparoscopy should be vertical
from the base of the umbilicus (not in the skin below the
umbilicus).
o Care should be taken not to incise so deeply as to enter
the peritoneal cavity.
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Phase III – Abdominal Entry
Primary Port
o Skin incision - Vertical within the
umbilicus:
1. The abdominal wall is at its thinnest.
2. The abdominal wall is least vascular.
3. The normally loosely applied parietal
peritoneum is strongly adherent, and
all layers are fused to form the
attachment of the falciform ligament.
4. Cosmetic.
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Phase III – Abdominal Entry
Primary Port – closed entry
Insertion of Veress needle:
o Pencil grip
o Vertical, then towards pelvis
o Valve open: as abdominal pressure is negative→ the air will
flow inside → pushing the bowel down!
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Phase III – Abdominal Entry
Primary Port – closed entry
Insertion of Veress needle:
o Two audible clicks are usually heard as the layers of
the umbilicus are penetrated – sheath and peritoneum
OR
o Sensing the “give” of the tissues!
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Phase III – Abdominal Entry
Primary Port – closed entry
Insertion of Veress needle:
o Stop advancing the needle once inside the peritoneal
cavity.
o After 2 failed attempts to insert the Veress needle:
1. Hasson’s technique
2. Palmer’s point entry: 3cm below the left costal margin in mid
clavicular line:
-Always use nasogastric tube to decompress stomach!
3. Optical entry
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Phase III – Abdominal Entry
Primary Port - GTG 49
o A disposable Veress needle is recommended.
o The lower abdominal wall should be stabilised in such a
way that the Veress needle can be inserted at right angles
to the skin.
o 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.
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Phase III – Abdominal Entry
ISGE - 2016
o A needle of appropriate length should be chosen to reach
the
o abdominal cavity, especially in obese women when the
LUQ site is
o used..
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Phase III – Abdominal Entry
o Needle insertion – Janos Balega:
1. BMI <25 → Verres needle angled since the umbilicus
is 0.4 cm caudal to the aorta.
2. BMI 25-30 → Verres needle perpendicular since the
umbilicus is 2.4 cm caudal to the aorta.
3. BMI >30 → Verres needle perpendicular since the
umbilicus is 2.9 cm caudal to the aorta
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Phase III – Abdominal Entry
Primary Port – closed entry
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Phase III – Abdominal Entry
Primary Port – closed entry
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o The saline test not 100% accurate.
o The most valuable test of correct placement of the Veress needle
is to observe that the initial insufflation pressure is relatively
low and is flowing freely:
✓ Non-obese: < 8mmHg
✓ Obese and Palmer’s entry: <10 mmHg
o If high pressure is noted → often this could be secondary to
needle tip being in contact with internal structures → gentle
withdrawal by few millimetres often help to bring the pressure
down!

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Phase III – Abdominal Entry
Primary Port – Closed entry - GTG 49
o An intra-abdominal pressure of 20–25 mmHg should be
achieved before inserting the primary trocar.
o The distension pressure should be reduced to 12–15 mmHg
once the insertion of the trocars is complete.
o The primary trocar should be inserted at 90 degrees to the skin,
through the incision at the base of the umbilicus.
o Once the laparoscope has been introduced it should be rotated
through 360 degrees to check for any adherent bowel.
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Phase III – Abdominal Entry
Primary Port – closed entry
o Routine inspection of the bowel below the entry site.
o Look for faecal contamination at the tip of the Verres needle or
Trocar.
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Phase III – Abdominal Entry
Primary Port – Commonest problem: failed entry
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Phase III – Abdominal Entry
o The risk of bowel damage after closed laparoscopy in
the three most tightly controlled trials: 0.3 in 1000.
o The risk of bowel damage after open laparoscopy
(Hasson) in the three best studies: 0.4 in 1000.
o 2 RCT compared the open and closed entry
techniques. A meta-analysis does not indicate a
significant safety advantage to either technique
(Cochrane Review 2007).
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Phase III – Abdominal Entry
Therefore, an open entry technique:
✓ Avoids type injuries including almost all vascular injuries !
✓ Does not reduce the incidence of type 2 bowel injuries, but
may allow immediate recognition!
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Phase III – Abdominal Entry - Verres Needle Injury
o It is probably more common than is diagnosed. It is often not
serious and may go unrecognized.
o It typically occurs when loops of intestine are adherent to the
anterior abdominal wall, and the perforation seals off promptly.
o Air insufflations into intestinal loop may occur, and the most useful
diagnostic sign is the presence of the characteristic faecal smell
on withdrawal of the needle.
✓ Expectant management is appropriate as long as the bowel
below the insertion site is inspected, and there is no apparent
tears.
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Phase III – Abdominal Entry – Primary Trocar Injury
o It is more of a major problem, and it is essential to be diagnosed at
the time of laproscopy.
o This most commonly arises when a loop of bowel (usually the
transverse colon) is adherent to the anterior abdominal wall.
✓ The primary trocar may pierce the bowel, passing through its
full thickness, and this may go completely unnoticed by the
surgeon.
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Phase III – Abdominal Entry – Transverse Colon
Always remove the laparoscope within the
cannula under vision to avoid missing this
particular injury
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o Subtle signs such as bowel wall haematoma should raise
suspicion and require careful inspection for possible injury.
✓ If in doubt → submerging bowel loops under irrigation
fluid may reveal air bubbles or spillage of bowel contents.
o If a trocar is accidentally inserted into the bowel → remove
the trocar and leave the cannula in place so that the site of
perforation can be identified.
Phase III – Abdominal Entry – Primary Trocar Injury
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49. RCOG Video
https://elearning.rcog.org.uk/minimal-access-
surgery/entry-techniques-laparoscopy/video
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Other injuries
o Vascular injury
o Retroperitoneal haemorrhage
o Bladder injury
o Injury to over inflated stomach
Phase III – Abdominal Entry – Primary Trocar Injury
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Phase III – Abdominal Entry
Secondary Ports
o Secondary ports are inserted under direct vision.
o An inadvertent injury from a secondary port could be
considered negligent.
o Remove under direct vision and visualize for port-site
active bleeding under 5mmHg pressure.
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Phase III – Abdominal Entry
Secondary Ports – GTG 49
o Secondary ports inserted under direct vision at right
angles to the skin at 20–25 mmHg pneumoperitoneum.
o Inferior epigastric vessels should be visualised
laparoscopically prior to secondary port placement.
o Once the trocar has pierced the peritoneum it should be
angled towards the anterior pelvis.
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Phase III – Abdominal Entry
Secondary Ports - principles
1. Before Trendelenberg tilt!
2. Avoid inferior epigastric vessels.
3. Avoid superficial vessels by trans-illuminating the
abdomen.
4. Avoid tunnelling by inserting the port perpendicular
to the abdominal wall till the peritoneum!
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Phase III – Abdominal Entry
Secondary Ports
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Phase III – Abdominal Entry
Secondary Ports
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Phase III – Abdominal Entry
Primary port - Alternatives to closed entry
1. If there is risk of umbilical adhesions - previous
(midline) laparotomy.
2. In very slim or morbidly obese women.
3. Failed saline test or Veress insertion x2.
4. Unsatisfactory closed Veress insufflation.
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Phase III – Abdominal Entry
Primary port - Alternatives to closed entry – GTG 49
1. When Hasson open laparoscopic entry is employed,
confirm that the peritoneum has been opened by
visualising bowel or omentum
2. Palmer’s point is the preferred alternative trocar
insertion site, except in cases of previous surgery in this
area or splenomegaly.
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Phase III – Abdominal Entry
Primary Port – Direct entry
o Port is inserted directly without pneumoperitoneum.
o Never use it without optical ports!
o Optical port needs significant axial thrust through the
dominant hand compared to bladed trocars → therefore,
they may not eliminate the risk of visceral and vascular
injury!
✓ but there is good chance of identifying them.
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Phase IV – Surgery
1. Minimal bowel handling.
2. Use atraumatic grasping forceps for bowel handling.
3. Careful tissue dissection.
4. Manipulate and dissect under vision.
5. Limit adhesiolysis to clinically indicated cases only.
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Phase IV – Surgery
6. Removal and reinsertion through the secondary ports must
be under vision to ensure that bowel loops are not
accidentally picked up and hung over the instruments.
7. Limit the use of thermal energy when working close to or on
bowel wall.
8. Periodic checking of laparoscopic instruments for insulation
failure.
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Phase IV – Surgery
9. Remember that even though the mucosa may be intact, damage to the
seromuscular layer can cause an area of weakness → may result in
mucosal perforation during the postoperative period.
10. Jacuzzi Test:
✓ Following extensive dissection of the rectosigmoid where integrity
may have been compromised.
✓ Obstruct the sigmoid lumen by compressing against the pelvic brim or
with a soft Johann forceps.
✓ Fill the pelvis with water.
✓ Insufflate the rectum with air using a 50 ml bladder syringe → If any
bubbles are seen → a perforation has occurred.
11. If there is any doubt as to whether injury has occurred or repair is
required, the opinion of the bowel surgeon should be sought.
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Phase IV – Surgery
Exit Technique GTG 49
o 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.
o Secondary ports must be removed under direct vision to ensure
that any haemorrhage can be observed and treated, if present.
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Phase IV – Surgery
Wound closure
o Proper closure of fascia within umbilical port site to prevent
wound dehiscence or hernia
o Avoid hernia risk by closing sheath:
-Midline port sites > 10mm
-Lateral port sites > 7 mm
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Phase V – Postoperative
o Women with suspected bowel injury should be promptly
admitted for:
1. Assessment – Senior Review
2. Intravenous rehydration
3. Parenteral antibiotics
4. Nasogastric tube
5. Investigations:
-Blood tests: FBC and CRP
-Abdominal X-ray and CT with contrast of the abdomen and
pelvis may reveal air under diaphragm, distended bowel
loops with multiple fluid levels or localized fluid/air
collection due to abscesses.
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Phase V – Postoperative
o Bear in mind that physical signs may vary from a rigid
abdomen to only localized tenderness depending on the
extent of faecal contamination of the peritoneal cavity.
o Early involvement of a colorectal surgeon.
o Assess the patient not the investigations!
o If the patient’s condition is unclear → low threshold for an
exploratory laparoscopy or laparotomy.
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Risk Management
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A-C-T
The underlying principles of the strategies to improve patient
safety and outcome can be remembered by the acronym of ACT:
A = Awareness that a complication can occur at Anytime once the patient
enters the operating room through to the postoperative phase.
C = Communication and Counselling skills are essential in
preventing and dealing with complications.
T = Teamwork and Training are important risk management
principles in protecting and ensuring patient safety from harm due to
the frequent introduction of new technologies or techniques.
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9 Possible reasons for delayed diagnosis of
bowel injury
1. Injury outside the operating field caused by bowel retraction or
handling with sharp instruments.
2. Unrecognized injury on entry or during closure of port sites.
3. Thermal injury with subsequent bowel necrosis and breakdown.
4. Perforation of a mechanically devitalized bowel or following
mesenteric thrombosis.
5. Postoperative abscess with subsequent fistula formation.
6. Herniation through port sites.
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9 Possible reasons for delayed diagnosis of
bowel injury
7. Postoperative narcotic medications masking pain.
8. Atypical presentation due to different inflammatory and
immunological response.
9. Clinician denial !!
-As surgeons, we naturally find it difficult to accept that complications
can and do occur, and the tendency is often to bury our heads in the
sands!
-We love to celebrate our success , but it is much harder to confront our
failures!
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