- A vertical incision through the skin corresponding to the size of the trocar is made at the base of the umbilicus. Note that this incision ideally is made at the base of the umbilicus and not infraumbilically as is classically taught. This is because the distance between skin and peritoneum on the anterior abdominal wall is shortest at the base of the umbilicus. In addition, the peritoneum is firmly attached, which will prevent tracking through the subcutaneous tissue and subsequent retroperitoneal insufflation.
- The Veress needle is inspected for sharpness and a functioning spring mechanism to extend the protective sheath in the absence of pressure.
- The anterior abdominal wall inferior to the umbilicus is grasped with the nondominant hand and the umbilicus is moved in the caudad direction, further displacing it below the bifurcation of the aorta. Alternatively, the incision may be elevated by grasping the edges of the umbilical incision with two Alice clamps and lifting.
- The tip of the Veress needle is held in the dominant hand between the thumb and forefinger while the ulnar palm rests on the patient's abdomen. The needle is inserted carefully at a 90-degree angle, through the base of the umbilicus, millimeter by millimeter, until a click is heard and resistance is no longer felt, identifying intraabdominal placement.
- A saline-filled 10-cc syringe is attached to the Veress needle and aspirated, inspecting for blood or bowel contents. If only bubbles are visible, saline is injected and observed to fall from the trough on the needle into the peritoneal cavity.
- The syringe is removed, the insufflation tubing (with CO2 turned on low flow) is attached, and the initial IAP is observed. If the pressure is greater than 10 mm Hg, the needle should be removed quickly to avoid retroperitoneal insufflation, which further displaces the peritoneum from its attachment to the anterior abdominal wall. A second needle placement attempt is then made.
- Once intraperitoneal placement is confirmed, CO2 pneumoperitoneum is obtained. Insufflation up to an IAP of 20 to 25 mm Hg, as initially described by Reich and others, remains one accepted method. This temporary increase in IAP increases the distance between abdominal viscera and the anterior abdominal wall (in the absence of adhesions) during primary sharp trocar placement through the umbilicus. It is also extremely beneficial for surgeons with small hands, who may find it difficult to grasp and further elevate the abdominal wall if the initial pressure is less than 20 mm Hg.
- The end of the sharp trocar is held in the palm of the dominant hand, with the forefinger extended along the shaft as close to the sharp tip as possible. The tip is inserted through the umbilical incision until the fascia at the base of the umbilicus is felt. Insertion is carried through at a near-90-degree angle until the
- tip is felt to pass through the peritoneum. The trocar is then directed toward the pelvis to minimize risk of vascular or bowel injury.
- After placement of the primary trocar, the intraabdominal placement is confirmed visually and the IAP is reduced to 12 to 15 mm Hg.
Thursday, February 12, 2015
Laparoscopy is a minimally invasive surgery, a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.0 cm) elsewhere in the body. Laparoscopic surgery includes operations within the abdominal or pelvic cavities.
Laparoscopes are telescopes that vary in size from 2 to 10 mm. Zero-degree, 30-degree, 45-degree, and 70-degree viewing angles are available.
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
Reduced hemorrhaging, Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring ,Less pain, leading to less pain medication needed.Although procedure times are usually slightly longer, hospital stay is less. Reduced risk of acquiring infections.
Proper patient positioning is paramount. The surgeon should position the patient so as to prevent any excessive pressure on the lower extremities. Nerve injuries can result from improper placement of the lower extremities in stirrups. Lithotomy position with access to steep Trendelenburg is appropriate. The physician should discuss with anesthesia personnel decisions regarding whether the arms should be extended or “tucked” along the sides of the patient. The latter requires particular attention to prevent any trauma to the hands and fingers when the table is maneuvered.
With the patient in the low lithotomy position and the legs supported in stirrups, the buttocks should protrude slightly from the lower edge of the table. The lateral aspect of the knee should be protected with padding in the stirrup to prevent peroneal nerve injury. The knees should be kept in slight flexion to minimize stretching of the sciatic nerves and to provide increased stability in the Trendelenburg position. With respect to positioning of the arms, care should be taken not to stretch or traumatize the brachial plexus.
It has been advocated that an angle of 145 degrees between the abdomen and the lower extremity (thigh) is ideal, providing the surgeon with adequate space for instrumentation.
An array of instruments designed to facilitate operative laparoscopic procedures continues to evolve.
The video equipment should include a three-chip camera, a processor, a 300-watt xenon light source with fiberoptic cable, a high-resolution monitor, and a video recorder.
An operating room table that allows 30 degrees of flexion (Trendelenburg position) is ideal for visualization of the deep pelvis. Shoulder braces (Stierlen-Maquet Shoulder Braces, Siemens Medical Systems, Englewood, CO) placed at the acromioclavicular joints and the arms placed at the patient's sides will minimize nerve injuries.
For most procedures, the pneumoperitoneum may be maintained with an insufflator that flows at a rate of 2 to 7 L/min. High-flow insufflators that achieve up to 30 L/min are available and will maintain the pneumoperitoneum during procedures that allow escape of large amounts of CO2, such as during tissue morcellation.
Carbon Dioxide Warmer
There is evidence that warmed CO2 is less irritating to the peritoneal surface and, therefore, may cause less adhesion formation. CO2 warmers are commercially available.
Unipolar electrosurgical instruments are used to cut and coagulate tissue. Cutting occurs when there is sufficient voltage (at least 200 volts) between the electrode and the tissue to produce an electric arc. This arc concentrates the current to points along the tissue, resulting in a cutting effect. In contrast to cutting current, coagulation is produced through instrument contact with the tissue. Contact allows heating of the tissue followed by irreversible cellular damage, evaporation of intracellular water, and contraction of blood vessels and surrounding tissue. Electrosurgical burns may occur due to insulation failure, direct coupling (activated electrode makes unintended contact with another metal object in the area of the surgical field), or capacitive coupling (induction of stray current to a surrounding conductor through the intact insulation of an active electrode).
Bipolar electrosurgical instruments contain the electrical current between an active and return electrode, usually the two blades of forceps. The flow of alternating current is passed between the two electrodes rather than passing through the patient to a grounding pad. This eliminates the risk of capacitive coupling and stray current.
Obtaining Intraabdominal Access
Insufflation of CO2 through a Veress needle is the most common method of entry, although some would argue the open technique should become the method of choice. One technique of access using a Veress needle is performed in the following manner: