Laparoscopic Course: General Principles of Laparoscopy: Specific Aspects of Transperitoneal Access (R.Bollens)

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Laparoscopic course:

General principles of laparoscopy:

Specific aspects of transperitoneal access (R.Bollens)

Veress needle insertion:

Most frequent accident in laparoscopy occurs during the introduction of the

Veress needle or of the first port. Veress needle can be reusable or disposable.

Disposable is more expensive but the sharpness is perfect for each procedures.

Before introduction, needle must be tested: traction and release must be

completely free of friction and sharp part is completely covered after release.

The skin incision is adapted for port size. For a 10 mm port:

(2 x 3.14 x (10/2)) / 2 = 15 mm and for a 5 mm port: (2 x 3.14 x (5/2))/2 = 7.5

mm. Shorter skin incision increase risk of injury during the port introduction. In

this situation, the abdominal wall move down and the blade of the port can

injure intra abdominal organs. A naso gastric tube must be placed before any

abdominal introduction up to the umbilicus to avoid gastric injury.

Abdominal wall is lifted up and Veress needle is introduced with continuous

pressure in the abdomen. One click is classically eared on the midline and two

clicks somewhere else. Sometimes peritoneum adds one more click in fatty

patient for example.


A 20 cc syringe is used to test the good positioning:

1. Suction: . Blood sign vascular injury and conversion is recommended

. Gas sign bowel injury; needle must be replaced and

laparoscopic suture on the bowel control the injury

2. Injection followed by suction of 20 cc of air or saline:

. Nothing is aspirated: needle is well placed

. Air or saline is aspirated: needle is in the extraperitoneal

space

Veress needle is connected and the insufflator starts on low gas flow.

Abdominal wall is lifted up to help insufflation. High peak pressure occurs when

needle is closed to the omentum. In this case, you must mobilised needle in its

axis. In the field of the liver, Veress can be placed trough this organ without any

impact on the creation of the pneumoperitoneum. For this reason the needle

must be mobilised only in its axis. Good insufflation is controlled by abdominal

percussion on the area of the liver or of the spleen (tympanism) before to

increase gas flow on highest adjustment.


Port introduction:

When intra abdominal pressure is at least 10 mm Hg, the Veress needle is

removed and replaced by the first 10 mm port. More than 10 mm of pressure

give enough resistance to introduce the port without risk to push down the

abdominal wall. Port is introduced in 90° from the skin or slightly in direction of

operating field. An excessive oblique introduction reduces port mobility and

increase abdominal wall injury. When first port is placed the valve is opened

few seconds to ear gas leakage and to confirm intraperitoneal positioning.

Insufflator is connected and the optic is introduced. Visual examination must be

perform to exclude any injury occurred during this blind part of the installation.

Other ports are placed under view control.

Open approach (Hasson technique):

In case of previous surgery or major intra abdominal infection, an open

procedure must be performed. Personally, I don’t use retractor and I prefer to

use grasping forceps (Kocher). Skin is incised classically and fatty tissue is

opened to see the aponevrosis. The aponevrosis is grasped between two Kocher

and incised. Muscular fibres are dissected to show the next plan (Douglas arch

or peritoneum for ex.). The next plan is grasped between two others Kochers

and incised. The Two first Kocher are removed. All successive plans are opened

using the same principles. When the peritoneum is opened, a purse spring suture

is placed on the peritoneum and the aponevrosis. The optic is introduced in a 10


mm port and its tip is placed like a blunt port in the cavity. The port is pushed on

the optic, inside the abdomen, and the purse spring suture is closed to avoid gas

leakage. Never introduce the port alone because its tip is sharp. Insufflation can

be finally installed.

Gasless laparoscopy:

To create a working space without gas, abdominal wall is lifted by a static

system. This technique avoids physiological impacts in relation with intra

abdominal pressure or gas resorption. The working space is not a hemisphere

but more a trapezoid volume due to the lifting system. Main disadvantage is

certainly the conflict between lifting system and laparoscopic instruments. I

think that this approach is certainly not perfect and in most cases we can

perform classical laparoscopic procedures in low abdominal pressure (8 to 10

mm hg).

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