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    Safe Entry and Pneumoeritoneum

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    Novi Ajah
    This document discusses techniques for safe entry and pneumoperitoneum during laparoscopic procedures. It describes: 1) The goals of peritoneal access including good visualization, ergonomic positioning, and patient safety. 2) The two main entry methods - closed technique using a Veress needle for insufflation and open technique using Hasson's direct trocar insertion after incising fascia and peritoneum. 3) Key technical aspects for each method including needle/trocar selection, abdominal wall lifting, insertion angle, and confirmation of intraperitoneal placement. Slow, careful insufflation while monitoring pressure indicators is emphasized.

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    Safe Entry and Pneumoeritoneum

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    Novi Ajah
    40 views31 pages
    This document discusses techniques for safe entry and pneumoperitoneum during laparoscopic procedures. It describes: 1) The goals of peritoneal access including good visualization, ergonomic positioning, and patient safety. 2) The two main entry methods - closed technique using a Veress needle for insufflation and open technique using Hasson's direct trocar insertion after incising fascia and peritoneum. 3) Key technical aspects for each method including needle/trocar selection, abdominal wall lifting, insertion angle, and confirmation of intraperitoneal placement. Slow, careful insufflation while monitoring pressure indicators is emphasized.

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    This document discusses techniques for safe entry and pneumoperitoneum during laparoscopic procedures. It describes: 1) The goals of peritoneal access including good visualization, ergonomic positioning, and patient safety. 2) The two main entry methods - closed technique using a Veress needle for insufflation and open technique using Hasson's direct trocar insertion after incising fascia and peritoneum. 3) Key technical aspects for each method including needle/trocar selection, abdominal wall lifting, insertion angle, and confirmation of intraperitoneal placement. Slow, careful insufflation while monitoring pressure indicators is emphasized.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    40 views31 pages

    Safe Entry and Pneumoeritoneum

    Uploaded by

    Novi Ajah
    This document discusses techniques for safe entry and pneumoperitoneum during laparoscopic procedures. It describes: 1) The goals of peritoneal access including good visualization, ergonomic positioning, and patient safety. 2) The two main entry methods - closed technique using a Veress needle for insufflation and open technique using Hasson's direct trocar insertion after incising fascia and peritoneum. 3) Key technical aspects for each method including needle/trocar selection, abdominal wall lifting, insertion angle, and confirmation of intraperitoneal placement. Slow, careful insufflation while monitoring pressure indicators is emphasized.

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    SAFE ENTRY AND

    PNEUMOPERITONEUM

    Herbert Situmorang
    Jakarta Center for Gynecology Endoscopy
    Good entry / access :
     Pump up operator-confidence
     Better visualization
     Better ergonomics
     Less anaesthesia problems
     Less post operative problems
    Major complication during 1000 laparoscopies
    Major complication during 1000 laparoscopies

    Asch R, Studd J, 1999


    Scope of discussion
     Goal of peritoneal access
     Entry methodes
     Technical aspects in veress insertion and
    insufflation
     Technical aspects in hasson’s open entry
    Goal of peritoneal access
     Good visualization of the peritoneal cavity
     Ergonomic position of hand instruments
     Maintenance of patient safety :
    vascular
    visceral
    incisional complication
     Cosmetically acceptable result : size, location
    Methods
     Closed (Blind) Technique
    - Veress needle: insufflation  optic trocar
    - Direct trocar insertion : with trocar, without
    trocar (ternamian)

     Open Technique (Hasson)


    - Direct trocar insertion after incising the
    fascia and peritoneum
    Pre-entry Evaluation
     Abdominal Wall thickness
     Previous surgery
     Possibility of severe adhesion
     Equipments : veress needle, trocars type
     Operating table height
    Closed technique- veress
     Veress needle selection
     Veress needle test, grip
     Patient’s position
     Umbilical incision
     Abdominal wall lifting technique
     Veress needle insertion
     Confirmation of veress position
    Veress needle selection
     Options : 12-14-16 cm length
     Determinant factor : abdominal wall
    thickness
     Check the spring mechanism and the
    patency : VITAL !!
    Veress grip
     Hold the veress needle like a dart
    Patient’s position
     FLAT !
     Trendelenburg position : difficult to
    estimate the proper angle of veress/trocar
    insertion
    Umbilical incision
     Transverse incision (Inferior border)
     Vertical incision
     Transumbilical

     Small incision vs wide incision

    Risk : injury of incision to visceral organs !


    Abdominal wall lifting
     Use of towel clips or Ellis clamp
    Advantages :
    stabilize the umbilicus :
    - prevents intraperitoneal incision
    - prevents overshoot of veres/trocar insertion
    Disadvantages :
    more scar and post op pain
    false safety : peritoneum is not lifted by doing
    this
    Abdominal wall lifting
     Use of surgeon’s left hand :
    advantage :
    no additional scar / pain
    disadvantage :
    smaller hand cannot hold the abd firmly
    folding of fascia
     Alternatives : both surgeon and first assistant’s
    hand lift the abdomen side by side
    Veress needle insertion
     Put the needle tip inside the incision, then
    lift the abdomen
     Insert the veress in 45o elevation angle
    and perpendicular to the abdominal wall

     FEEL the 2 “CLICK SOUND”


    Confirmation of veress position
     Waggle test : veress needle movement
     Irrigation test
     Aspiration test
     Hanging drop test
     Insufflator indicators
    Automatic insufflator indicator

    Intraperitoneal pressure

    CO2 Flow

    Total gas used


    Slow insufflation with careful hold
    over veress needle

    Look at the indicators carefully !


    Trocar insertion
    Reducing risk :
     Anatomy
     Ergonomics
     Insertion dynamics
     Abdominal pressure
    Trocar grip
    Lift abdominal wall as much as possible

    Insert the trocar carefully


    Primary trocar insertion
     Lower the operating table as low as it can
     Two giveways: fascia and peritoneum
     Whoozing sound
     Use as minimum power as possible
     Abdominal pressure : can be raised up to
    25 mmHg without any side effect (Tsaltas,
    Reich, 2000)
    Trocar insertion
     Put the trocar tip JUST inside the
    abdoment !!
    Push the canulae further only after we retract
    the trocar
    Insert the camera

    Do not turn the CO2 flow


    on before you see the
    internal abdomen !
    Accessory trocar

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