An Opinion on Entry Techniques
In 1988 Harry Reich performed the first laparoscopic hysterectomy and now in 2010 we laparoscopists only have a depressing 15% of the market despite the fact that we believe this to be the best procedure. In 2001 nobody in the US had done more than 20 laparoscopic prostatectomies and in 2010, 85% are performed in this minimally invasive way.
Urologists have been forced to learn the procedure by patient demand for a procedure that has not scientifically been shown to be any better than the traditional surgery but is less painful and associated with a faster recovery. Why hasn’t there been a similar patient demand for the laparoscopic approach to hysterectomies?
Actually there has but it has been diminished by those gynecologists who have abused their position of trust with their patients by stating that the patient was not a good candidate because of her weight, previous surgery, that the surgery was experimental or more dangerous. Those opinions only coming from gynecologists who do not know how to perform such an operation and for questionable reasons do not refer surgery to those who can.
We are never going to convince many gynecologists of the benefits of minimally invasive surgery but we would do well to try to decrease the incidence of complications that gives fuel to their fire.
It is accepted that complications of surgery are underreported and in fact there is no real definition of complications so it is hard to document a rise or fall in the incidence. It is largely held however that more than half of the serious complications occur on entry and it is that subject on which I wish to comment.
In 2000 Professor Ray Garry hosted a “Consensus on Entry Techniques” conference in Middlesborough, England. Although we did not actually come to agreement on all topics there were a number of items we all felt important.
We all agreed that the direct entry of a trocar was the most dangerous approach although many experienced surgeons have used this method without problems.
We agreed that there were essentially two major types of injuries, those to the bowel and those to the retroperitoneal vasculature. Although the Hasson open technique should avoid the latter this method has no advantage over other methods in avoiding injuries to bowel adhered to the abdominal wall.
We agreed that Palmer’s Point in the left upper quadrant of the abdomen was a place with a very low incidence of adhesion formation providing the patient had not been subjected to surgery in that area, consequently being an ideal location for placement of the Verres needle. Of course insertion of the Verres needle in this site completely avoids injury to the retroperitoneal vasculature also.
We agreed that the initial pressure of CO 2 should be taken to 25mm of mercury because this creates a bigger window of safety between the distended abdominal wall, the bowel and the retroperitoneum. This pressure also offers…
