Safe Intraperitoneal Placement for Laparoscopic Entry

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Video Description

This video demonstrates entry techniques at laparoscopy.

Presented By

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Dr. George Vilos
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Dr. Angelos Vilos
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Dr. George Jacob
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Dr. Basim Abu-Rafea
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Dr. Artin Ternamian


Western University & University of Toronto

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Video Transcript: Safe Intraperitoneal Placement for Laparoscopic Entry

This is a presentation of the Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, at Western University. Veres’s needle entry is the most commonly used approach by the gynecologist for laparoscopic entry. It has been associated with a small risk of bowel and major blood vessel injury. In fact, 50% of laparoscopic injuries occur at the time of entry. A landmark study showed that the umbilicus is at, or caudad to, the aortic bifurcation, depending on body mass index. 

The lead surgeon in this presentation has described a technique to displace the umbilicus at the time of entry to minimize laparoscopic injuries. The surgeon first palpated the aortic pulse to determine the location of the aortic bifurcation relative to the umbilicus. The assistant then uses both hands to pull the skin below the umbilicus in a caudal and upwards direction for maximal displacement. On average, a caudal displacement of 6cm from the sacrum and great vessels can be obtained. Next, a 1cm vertical infraumbilical incision is made.

With the assistant maintaining caudal displacement, the Veress needle is placed 90 degrees to the skin until the peritoneum is entered. Successful intraperitoneal entry is confirmed based on an opening pressure that is less than 9mm of mercury. In this example, the opening pressure was 4mm of mercury. The alternative to an umbilical Veress needle entry is to use the left upper quadrant, which will be described in detail in this video. 

There is an increased risk of laparoscopic entry injuries in patients who are very thin, very obese, with suspected bowel adhesions, or intraoperatively in patients who have had multiple umbilical Veress needle entries that were not successful. In such patients, the left upper quadrant should be considered. It is located 3cm below the left subcostal border in the midclavicular line. Contraindications include previous splenic or gastric surgery, significant hepatosplenomegaly, portal hypertension or gastro-pancreatic masses.

First, use an orogastric or nasogastric tube to empty the stomach. Next, a 1mm to 2mm incision is made at the left upper quadrant. The Veress needle is then inserted at 90 degrees into the skin through the incision. After the Veress needle enters the peritoneum, entry pressure is assessed. An entry pressure of less than 9mm is suggestive of successful intraperitoneal Veress placement. Following intraperitoneal insufflation, an endoscopic threaded imaging port or endo tip is used to insert the camera port, which is a visualized, trocar-less cannula entry.

Previous studies have shown that 50% of bowel and vascular injuries occur during the primary entry, 80% of which are due to the insertion of the primary trocar. This visualized trocar-less entry technique was designed to allow real-time recognition of entry and to replace linear penetrating force with radial torque. 

In this graphic, one can see that the layers of the abdomen are tented away as the port is inserted in a corkscrew manner. Studies have shown that in 5,000 patients who had a laparoscopy using this approach, no bowel injury was identified that was due to the cannula. This technique was found to be feasible, reproducible, and highly adaptable. 

After the peritoneal entry is obtained using the Veress needle, the abdomen is insufflated to 25mm of mercury. The volume of carbon dioxide insufflated is ignored. The Veress needle is removed, and the surgeon inserts the cannula within the umbilical incision previously created. Once the cannula is secure within the skin, a zero-degree laparoscope is inserted within the sheath so that the tip of the laparoscope is 1cm away from the end of the cannula. 

Here the surgeon demonstrates the technique used for entry. With the assistant holding the laparoscope, the surgeon lowers the cannula perpendicular to the abdomen and rotates clockwise, using minimal downward force. The cannula tip tents the layers of the abdomen outwards as the cannula travels downwards into the peritoneal cavity. The insufflation pressure is then reduced to 15mm of mercury, and the rest of the laparoscopy is conducted in the usual manner. 

After the surgery is completed, the sheath is rotated in a counter-clockwise manner, under visualization, to ensure that the bowel or omentum is not trapped within the layers of the abdomen. The abdominal layers close like the shutters of a camera as the sheath is removed. As is typical after a laparoscopy, the fascia in the umbilical port is not closed. 

This concludes our video on Safe Intraperitoneal Placement for Laparoscopic Entry.