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Performing a Safe Laparoscopy

THE PNEUMOPERITONEUM

The laparoscopic surgeon should check the position of the patient prior to initiating the pneumoperitoneum. Positioning the patient on the operating room table is critical and will significantly increase intra-abdominal visualization.

Pneumoperitoneum using a Veress Needle

We always create the pneumoperitoneum using a disposable Veress Needle or an Auto Suture SURGINEEDLE*. We have totally disregarded reusable Veress Needles. Potential catastrophes have occurred on our surgical service when the spring of the reusable Veress needle malfunctioned transforming the Veress needle into an uncontrolled harpooning device. In addition, we continue to question the sterility of these reusable needles. Veress needles come in two lengths (120 cm and 150 cm); the longer version is obviously for obese patients.

Pneumoperitoneum using a Veress Needle

1. Preparation of the Abdomen: The entire, anterior abdominal wall should be prepped from mid thigh to the nipple line and as lateral as possible. Laparoscopic procedures can occasionally become very difficult and may require the insertion of additional trocars away from the original operating site.

2. Grounding the Patient: All patients, without exception, should be properly grounded.

3. Insertion of the Veress Needle: The safest access into the intra-abdominal cavity with a Veress needle is the sub-umbilical area. The anterior abdominal wall is the thinnest at this level and all fascial layers are fused into single fascial planes. Thus, the operator should always attempt to insert the Veress needle at this site in the virgin abdomen.

In morbidly obese patients, use two traumatic towel clips on each side of the umbilicus to elevate the abdominal wall prior to attempt to insert the Veress Needle.

 Step 1: Elevating the Anterior Abdominal Wall

The anterior abdominal wall needs to be elevated in order to distance it from the intra-abdominal contents. This is done by grabbing the abdominal wall directly under the umbilicus with one hand. If the patient is overweight, two towel clamps can be used on each side of the umbilicus to achieve the same result.

 Step 2: The Incision

A 1 mm incision is made with a # 11 Scalpel below the umbilicus.

 Step 3: Inserting the Veress Needle

The spring function or the retraction capability of the Veress Needle is checked. The operating table should be in neutral or flat position. The needle is then slowly inserted into the incision. It is angled toward the pelvis and advanced. The operator should feel or sense the needle passing through two distinct planes.

The needle is advanced and withdrawn several times. If this is done easily and without obstruction, the tip is in proper position.

 Step 4: The Saline Test

Although we no longer perform this test routinely, all neophytes laparoscopic surgeon should do so. Ten cc of normal saline is injected. This should be done easily. The abdominal pull is then released. The Veress needle is then filled to the rim with normal saline (or a open syringe can be used). The tension on the skin is resumed and the level of saline should immediately drop if the needle is in proper intra-abdominal position.

 Step 5: Initiating the Insufflation

The Veress needle is then connected to the CO2 insufflation tubing (a filter should be used). Insufflation is initiated at a low flow. Intra-abdominal pressure recorded at this point should not exceed 8 mm Hg. Entry pressure at low flow should be checked immediately while the abdominal wall is still elevated. If higher, move the needle around or resume the pull on the skin or anterior abdominal wall. If the pressure is too high, the Veress needle it is not in the right position and needs to be removed. Begin again.

If in place, switch to high flow and inflate the intra-abdominal cavity.

Pneumoperitoneum using the VERSASTEP SYSTEM™
 
USSC   VERSASTEP™

The Versa-Step System is an integrated system combining a Nylon stretchable sheath over a Disposable Veress needle. Once inserted, the sheath is dilated by inserting the trocar [with a dilator in place]. The real advantage of this system is that it has no cutting entry blade, thus dramatically decreasing trocar site bleed and the potential for an intra-abdominal injury. In addition, it creates a smaller fascial defect which does not need to be closed  [up to 12mm].

 
 Insertion of the VersaStep System Trocar
     

Following insufflation the expandable needle system is inserted, the needle is withdrawn leaving the expandable sleeve in place.

 
 

 

 

A tapered blunt dilator is inserted through the sleeve, dilating the tract created by the needle.

 
 

 

 

The trocar is maintained in place by the expandable sleeve.

 


Pneumoperitoneum with a Blunt Trocar
The blunt trocar is used to safely create a Pneumoperitoneum in the scarred abdomen. It is inserted by making an initial skin and a fascial incision. The fascial incision should be 1 to 1.5 cm in size. A long suture (2.0) is placed on each fascial edges. With finger dissection a tunnel or an opening into the intraabdominal cavity is gently created. The BluntPort* is then inserted. The foamgrip anchoring device is set and secured with the previously placed suture. The insufflation port is connected to the insufflation tubing and the pneumoperitoneum created.
Using a VISIPORT™ or Direct Visualization
IA 1 cm skin incision is made with a plain scalpel. A telescope is inserted into the VISIPORT OPTICAL TROCAR* and the path of entry of the VISIPORT OPTICAL TROCAR* into intra-abdominal cavity is visualized. The VISISPORT OPTICAL TROCAR* is advanced slowly through the different planes of the abdominal wall. These planes are cut slowly with the blade of the VISIPORT OPTICAL TROCAR* (at the tip of the instrument) until the intraabdominal cavity is reached. Pneumoperitoneum must be created or abdominal wall elevation must be performed prior to the insertion of the VISIPORT* OPTICAL TROCAR.

 

 

Using a Storz Termanian™ Trocar

The Termanian® Type trocar has greatly improved the safety and function of the re-usable trocar. This is the only re-usable trocar we  use. It is inserted via a small incision without a pneumoperitoneum and rotating  while advancing it. All the abdominal wall layers are well seen and visualized.

Maintaining the Pneumoperitoneum

A laparoscopy can be performed without significant, deleterious effect with intraabdominal pressures up to 20 mm Hg. However, some laparoscopic inguinal hernia repairs require higher pressures in the 18 and 20 mm Hg. range to achieve necessary additional exposure.

Our guidelines are simple.

bulletThe best operating intra-abdominal pressures are between 10 to 15 mm Hg. The visualization of this type of intra-abdominal pressure can be further enhanced by modifying the patients’ position (operating table position to Trendelenburg to reverse, etc.)
bulletHigher pressures in the 15 to 20 mm Hg range are suboptimal. There is a definite correlation with increased postoperative patient discomfort and recovery and the use of increased intra-abdominal pressure.
bulletPressures beyond 20 mm Hg are classified as dangerous with potential hemodynamic and pulmonary compromise and long term effects on the intra-abdominal wall musculature. When such pressures are used, some patients will actually report increased abdominal girth and a bloating post-operative feeling which persisted for months after the procedure in spite of intensive exercise.


       

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