2. Safe Entry and How to avoidSafe Entry and How to avoid
complicationscomplications??
؟
Mahmoud Zakherah
Prof. Obstertris and Gynecology
15-2-2014
E-mail:.mszakhera@yahoo com
3. IntroductionIntroduction
Laparoscopy is a very common
procedure in gynaecology.
Access to the abdomen is the one
challenge of laparoscopic surgery.
It was noted that complications of
laparoscopic surgery are mostly
entry related and independent on
complexity of surgery .
3
4. IntroductionIntroduction
To minimize entry related injuries,
several techniques, instruments, and
approaches have been introduced.
The life-threatening complications
include injury to the bowel, bladder,
major abdominal vessels, and
anterior abdominal-wall vessel.
4
5. IntroductionIntroduction
Other less serious complications
can also occur, such as post-
operative infection, subcutaneous
emphysema and extraperitoneal
insufflation.
Laparoscopic procedures are
minimal invasive surgicallyminimal invasive surgically but notnot
minimally invasive physiologically.minimally invasive physiologically.
5
7. Laparoscopic EntryLaparoscopic Entry
Access is the Key of SuccessAccess is the Key of Success
Entry into the peritoneal cavity is
the most dangerous part of the
procedure
Be careful…be careful…be
careful…
The pneumoperitoneumThe pneumoperitoneum – a
continuing mistake in laparoscopy
7
8. Laparoscopic EntryLaparoscopic Entry
A. Closed access
* Blind
Insufflated Veress Needle Entry(1932)
Non-insufflated Direct Trocar
Entry(1978)
* Visual Optical Trocar insertion(1994)
( Layer by layer)
8
13. Sites of Veress Needle EntrySites of Veress Needle Entry
1-Trans-umbilical:
Intra-umblical
Sub or supra umbilical (smiling
incision(
11-Extraumbilical
13
24. Veress needle safety testsVeress needle safety tests
(Tests for peritoneal entry)
The “hiss” sound test
Double click sound of the Veress needle
Irrigation test (the syringe test.)
Aspiration test (Palmer test)
Hanging drop of saline test
Insufflation of gas test
Needle movement test
26. Veress needle safety testsVeress needle safety tests
Hanging drop test HISS TEST
26
27. Number of Veress needle insertionsNumber of Veress needle insertions
attemptsattempts
Complication rates were as follows:
one attempt, 0.8% to 16.3%; at
2 attempts, 16.31% to 37.5%;
3 attempts, 44.4% to 64%;
More than 3 attempts, 84.6%
to 100%.
Complications were extraperitoneal
insufflation, omental and bowel injuries,
and failed laparoscopy.
28. 11-Extraumbilical
1.1. Left upper quadrant (LUQ,)Left upper quadrant (LUQ,)
PalmerPalmer’’s points point
Ninth or tenth intercostalNinth or tenth intercostal
spacespace
1.1. Transuterine Veress CO2Transuterine Veress CO2
insufflationinsufflation
2.2. Trans cul-de-sac CO2Trans cul-de-sac CO2
insufflation(Transvaginal)insufflation(Transvaginal)
30. LUQ, Palmer’s
point
3 cm below the left subcostal border
Elevation Of The Anterior Abdominal
Wall
Veress Needle Insertion
31.
32.
33. Prerequisites:
Emptying of the stomach by nasogastric
suction
No previous splenic or gastric surgery
No significant hepatosplenomegaly
No portal hypertension
No gastropancreatic masses
Left Upper Quadrant (LUQ,
Palmer’s) Laparoscopic Entry
34. Left Upper Quadrant (LUQ,Left Upper Quadrant (LUQ,
Palmer’s) Laparoscopic EntryPalmer’s) Laparoscopic Entry
It should be considered in patients
with:
Suspected or known periumbilical
adhesions
History or presence of umbilical
hernia
After three failed insufflation
attempts at the umbilicus.(SOGC Practice Guideline.193, 2007) (L:II-2 G:A)
41. Optical access trocarsOptical access trocars
i. Visiport uses a blade that strikes
the fascia and peritoneum under
laparoscopic guidance.
ii. Optiview uses a conical clear tip
that is rotated under laparoscopic
vision as it penetrates the fascia and
peritoneum
41
47. Laparoscopic PearlsLaparoscopic Pearls
Primary ports
45 angle of entry
Stay midline
Keep patient flat
If the same angle of insertion is used in
the Trendelenburg position, the trocar
may be directed at the great vessels
47
49. High pressure trocar entryHigh pressure trocar entry
Temporary higher inflation
pressure (25-30mmHg)
The use of transient HIP-Entry does
not adversely affect
cardiopulmonary function in healthy
women.
↑ separation between viscera and
anterior abdominal wall
May therefore reduce risk of injury
49
50. 14mm Hg 20-30mm Hg
The High Pressure Entry
The tip of the trocar can injure
.abdominal contents The tip of the trocar is away from
abdominal contents.
51. 3kg force
3kg force
25mm Hg
15 mm Hg
The tip of the trocar
touched abdominal
contents
> 4 cm maintained. the
tip of the trocar never
touched abdominal
contents.
Phillips et al Gynaecol Endosc 1999;8:369–74.
Trocar insertion requires
4to 6 kg of force
Tarney et al . Obstet Gynecol 1999;94:83–8.
<4cm
The High Pressure Entry
So the pressure of 25-30 mmHg is required
54. Direct Trocar EntryDirect Trocar Entry
Pneumoperitoneum with Veress
needle insertion has actually three
blind steps opposed to one in direct
trocar entry.
Several reports pointed out that,
direct trocar entry without
pneumoperitoneum, is a safe
alternative to Veress needle entry
(RCOG greentop guideline 2009)
54
55. Technique of direct trocar entryTechnique of direct trocar entry
(DTE(DTE((
Intra-umbilical skin incision wide enough
to accommodate the diameter of a sharp
trocar/cannual system.
The anterior abdominal wall adequately
elevated by the hand, and the trocar was
inserted directly into the abdominal
cavity, aiming towards the pelvic hollow
55
56. Technique of direct trocar entryTechnique of direct trocar entry
(DTE(DTE((
After removal of the sharp trocar, the
laparoscope was inserted to confirm the
presence of omentum or bowel in the
visual field then pneumoperitoneum
started
56
57. The advantages of direct trocarThe advantages of direct trocar
entry areentry are
The avoidance of complications related
to the use of the Veress needle as failed
pneumoperitoneum, preperitoneal
insufflation, intestinal insufflation, or the
more serious CO2 embolism
Faster than any other method of entry.
Immediate recognition and rapid
treatment of complications.
57
58. Succesful Direct Trocar EntrySuccesful Direct Trocar Entry
Relaxation: Adequate General anesthésia
Sharp Trocar: the sharper = safer
Adequate Incision
Elevation of the abdominal wall (not
necessary)
58
63. How Should Secondary Ports beHow Should Secondary Ports be
InsertedInserted??
The secondary trocar should be placed in
a well-controlled fashion under direct
visualization
A suprapubic trocar
Lateral lower pelvic ports
Transillumination of the abdominal wall will
often identify these superficial vessels and
aid in trocar placement. These trocars
should be placed under direct visualization
63
64. How Should Secondary Ports beHow Should Secondary Ports be
InsertedInserted??
Secondary ports must be inserted under
direct vision perpendicular to the skin,
while maintaining the
pneumoperitoneum at 20–25 mmHg
64
RCOG Guideline No. 49 May 2008
65. How Should Secondary Ports beHow Should Secondary Ports be
InsertedInserted??
During insertion of secondary ports, the
inferior epigastric vessels should be
visualised laparoscopically to ensure the
entry point is away from the vessels
65
RCOG Guideline No. 49 May 2008
66. How Should Secondary Ports beHow Should Secondary Ports be
InsertedInserted??
Once the tip of the trocar has pierced
the peritoneum it should be angled
towards the anterior pelvis under careful
visual control until the sharp tip has
been removed.
66
RCOG Guideline No. 49 May 2008
68. Safety Zones for AnteriorSafety Zones for Anterior
Abdominal WallAbdominal Wall
68
Epigastric vessels are
usually located in the area
between 4 and 8 cm from
the midline.
Staying away from this
area will determine the safe
zone of entry of the anterior
abdominal wall.
69. How Should Secondary Ports beHow Should Secondary Ports be
InsertedInserted??
Secondary ports must be removed under
direct vision to ensure that any
haemorrhage can be observed and
treated, if present.
69
RCOG Guideline No. 49 May 2008
70. Injury of Epigastric VesselsInjury of Epigastric Vessels
Management
direct pressure with the operating port
full-thickness abdominal wall suture
ligation
Foley catheter balloon tamponade.
Exploration of the wound
70
71. Elevation of the anteriorElevation of the anterior
abdominal wallabdominal wall
Many surgeons advocate elevating the
lower anterior abdominal wall by hand or
using towel clips at the time of Veress or
primary trocar insertion.
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
75. There are 3 subgroups of patients in whom
the creation of a pneumoperitoneum
can be problematic:
1. Obese and thin patients,
2. Patients with scars from
previous abdominal surgeries
3. patients with failed
insufflations.
76. Laparoscopic surgery in the obeseLaparoscopic surgery in the obese
womenwomen
Obesity changes the relationship of the
umbilicus to the aortic bifurcation.
In nonobese patients (BMI <25), the
umbilicus had a median location 0.4 cm
caudal to the bifurcation,.
In overweight (BMI 25 to 30) and obese
(BMI >30) patients, the umbilicus had a
median location 2.4 and 2.9 cm caudal to
the aortic bifurcation, respectively.
77. Laparoscopic surgery in very thinLaparoscopic surgery in very thin
womanwoman
Liable to more complications
The Hasson technique or insertion
at Palmer’s point is recommended
for the primary entry in women who
are very thin and women with
morbid obesity
RCOG Guideline No. 49 May 2008 Grade C
79. RCOG green top guidelinesRCOG green top guidelines
Primary incision for laparoscopy
should be vertical from the base of
the umbilicus (not in the skin below
the umbilicus)
The Veress needle should be sharp,
with a good and tested spring action
The operating table should be
horizontal (not in the
Trendelenburg tilt) at the start of
the procedure
79
80. RCOG green top guidelinesRCOG green top guidelines
An intra-abdominal pressure of 20–
25 mmHg should be used for gas
insufflation before inserting the
primary trocar (HPE).
The distension pressure should be
reduced to 12–15 mmHg once the
insertion of the trocars is complete
80
81. RCOG green top guidelinesRCOG green top guidelines
During insertion of secondary ports, the
inferior epigastric vessels should be
visualised laparoscopically to ensure
the entry point is away from the
vessels..
81
82. RCOG green top guidelinesRCOG green top guidelines
During insertion of secondary ports,
once the tip of the trocar has
pierced the peritoneum it should be
angled towards the anterior pelvis
under careful visual control until the
sharp tip has been removed
82
83. RCOG green top guidelinesRCOG green top guidelines
Secondary ports must be removed
under direct vision to ensure that
any haemorrhage can be observed
and treated, if present.
83
84. Risk of herniationRisk of herniation
Hernias at the site of laparoscopic
ports are significantly more
common with 12-mm trocars.
Close fascia, therefore, when you’ve
used any type of trocar that is 10
mm or greater in diameter.
Chiong et al .. 2010;75(3):574–580.
86. Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
Left upper quadrant (LUQ, Palmer’s)
laparoscopic entry should be considered
in patients with suspected or known 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)
87. 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;
however, waggling of the Veress needle from
side to side must be avoided, as this can enlarge
a 1.6 mm puncture injury to 1 cm in viscera or
blood vessels,
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
88. The Veress intraperitoneal (VIP-
pressure 10 mm Hg) is a reliable
indicator of correct intraperitoneal
placement of the Veres
needle;therefore, it is appropriate to
attach the CO2 source to the
Veress needle on entry. (II-1 A)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
89. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
90. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
91. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
92. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
93. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
94. Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007
No significant risk differences have
been found for bowel and vascular
injuries, when comparing the open-
entry to the closed-entry technique.
Evidence level A1 [11]
94
95. 20122012
An open-entry technique is
associated with a significant
reduction in failed entry when
compared to a closed-entry
technique, with no difference in
the incidence of visceral or
vascular injury.
96. Direct insertion of the trocar without
prior pneumoperitoneum may
bconsidered 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
97. Significant benefits were noted with the
use of a direct-entry technique when
compared to the Veress Needle.
The use of the Veress Needle was
associated with an increased incidence of
failed entry, extraperitoneal insufflation
and omental injury; direct-trocar entry is
therefore a safer closed-entry
technique.
20122012
98. 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)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
99. 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 not-superior to other trocars
since they do not avoid visceral and
vascular injury. (2 B)
Society of Obstetricians anSociety of Obstetricians an
Gynecologists of Canada 2007Gynecologists of Canada 2007..
100. Arm tuckingArm tucking
Avoid brachial plexus injury in
laparoscopic surgery by always
tucking the arms, instead of placing
them on arm boards that can
inadvertently be moved beyond
horizontal during the surgery.
Shveiky et al .. 2010;17(4):414–420.
101. Release of gas CompletelyRelease of gas Completely
Evacuate all gas and instruct the
anesthesiologist to perform five
manual inflations of the lungs
before the patient is taken out
of Trendelenburg position.
Phelps P, et al .Obstet Gynecol.
2008;111(5):1155–1160.
102. RecommendationsRecommendations
Surgeons intending to perform
laparoscopic surgery should have
appropriate training, supervision
and experience.
Surgeons undertaking laparoscopic
surgery should be familiar with the
equipment, instrumentation and
energy sources they intend to use.
102
