RCOG Basic Practical Skills Course Laparoscopy and entry RCOG Basic Practical Skills Course

Laparoscopic entry techniques What to expect: Position of patient Primary port closed entry Secondary port entry Primary port alternatives Exit techniques Reference to RCOG Green Top Guideline 49 - PREVENTING ENTRY-RELATED GYNAECOLOGICAL LAPAROSCOPIC INJURIES

1. Position Prone Stirrups/Lloyd Davis Non slip mattress Trendelenberg after ports

Green-top Guideline. No. 49 May 2008 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

2. Primary port closed entry Why intra umbilical entry? Fixed peritoneum Thin Least vascular Cosmetic

Green-top Guideline. No. 49 May 2008 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.

2. Primary port closed entry Insertion of Veress needle Pencil grip Vertical, then towards pelvis Double “click”

Green-top Guideline. No. 49 May 2008 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

Green-top Guideline. No. 49 May 2008 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

2. Primary port closed entry Saline test Withdraw Instil If no fluid, frank blood (or faeces) then proceed with insufflation

Green-top Guideline. No. 49 May 2008 The saline test not 100% accurate 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 After 2 failed attempts to insert the Veress needle, either the open Hasson technique or Palmer’s point entry should be used.

2. Primary port closed entry 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)

2. Primary port closed entry The greater the gas bubble & abdominal wall tension the less the risk of bowel injury Abdominal pressure= 8mmHg Abdominal pressure=25mmHg

Green-top Guideline. No. 49 May 2008 An intra-abdominal pressure of 20–25 mmHg should be achieved before inserting the primary trocar The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete

Green-top Guideline. No. 49 May 2008 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

2. Primary port closed entry Commonest problem - failed entry Insertion of subumbilical Veress needle

2. Primary port closed entry Closed entry can still cause bowel injury, especially if adhesions are present

2. Primary port closed entry Other injuries Vascular injury Retroperitoneal haemorrhage Bladder injury Injury to over inflated stomach

3. Secondary ports 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

Green-top Guideline. No. 49 May 2008 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

Obliterated umbilical artery 3. Secondary ports - Anatomy Round ligament Obliterated umbilical artery Rectus muscles Mid-line

3. Secondary ports - Anatomy Inf epigastric artery

4. Primary port – Alternatives 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

Green-top Guideline. No. 49 May 2008 When Hasson open laparoscopic entry is employed, confirm that the peritoneum has been opened by visualising bowel or omentum Palmer’s point is the preferred alternative trocar insertion site, except in cases of previous surgery in this area or splenomegaly.

5. Exit techniques Under direct view to identify: Bleeding Injury to omentum Injury to bowel - (partial/complete)

Green-top Guideline. No. 49 May 2008 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.

5. Exit techniques 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

Now show the Video: Closed laparoscopic entry technique Now show the video: Alternative laparoscopic entry techniques