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 increased rigidity of the abdominal wall making it less likely for a trocar to damage the blood vessels.
It is my opinion that the following technique performed carefully could exclude the vast majority of entry injuries and the tragedies the might result.
1. The patient should be flat.
2. The stomach suctioned with an orogastric tube by the anesthesiologist.
3. A verres needle inserted perpendicularly into the abdominal cavity through a small incision at the junction of the left mid-clavicular line and the costal margin . Puncture of the fascia and then the peritoneum can be appreciated
4. 10ml of saline inserted through the needle and negative pressure utilized to confirm intraperitoneal placement without complications.
5. CO 2 passed into the abdomen noting the initial pressure to be between 4 and 10 mm of mercury. ( it is normally higher in heavier patients than lighter patients). The total volume insufflated is not important, it is the pressure of 25mm of mercury achieved that is crucial and safe providing that the patient is not cardiovascularly compromised.
6. In a patient with a virgin abdomen a primary trocar can safely be placed through an incision in the base of the umbilicus. However my preference in all cases and strong recommendation in patients with previous abdominal surgery, is to utilize a 2mm scope that can be passed through the verres needle to confirm pneumoperitoneum and allow assessment of the periumbilical area for passage of the primary umbilical port under direct visualization.
7. A working laparoscope is then passed through the umbilical port, the left upper quadrant needle removed and the needle site assessed.
8. All accessory ports are then placed under direct visualization, avoiding injury. The intraperitoneal pressure can then be dropped to 12mm of mercury.
9. All trocars should be of an expanding or dilating design as opposed to cutting or bladed trocars.
10. After the procedure is finished and the ports removed, fascial sutures should be used to diminish hernia formation for all sites where the ports were 10mm or larger.
Quick, easy, safe, logical…
But then, this is just my opinion.
