Left upper quadrant laparoscopic placement: effects of insertion angle and body mass index on distance to posterior peritoneum by magnetic resonance imaging

Jain point laparoscopic entry in contraindications of Palmers point

BACKGROUND

This study was conducted to assess the efficacy of the Jain point to overcome the contraindications of Palmer's point. The Jain point lies on the left side of the abdomen at the L4 level, 10-13 cm lateral to the umbilicus. Due to its anatomical location, the Jain point is free from adhesions because postsurgical adhesions are encountered usually in the midline or the right side.

METHODS

This is a retrospective study conducted at a high-volume tertiary care referral center for advanced gynecological laparoscopic surgery, enrolling 8,586 patients who underwent laparoscopy at the center from January 2011 to March 2022. In this paper, we analyze 2,519 patients with a history of previous surgeries, who were operated using the Jain point.

RESULTS

In the 2,519 patients with a history of previous surgeries, the Jain point port was found to be adhesion free, regardless of the location of the scars, the number and type of previous surgeries, and those in whom Palmer's point was contraindicated. No major complications were reported, except for one case (0.04%) of small bowel injury, which was managed intraoperatively. The Jain point continued to function as the main ergonomic working port.

CONCLUSION

The Jain point offers an alternate safe entry port in previous surgery cases for laparoscopic surgeons of various specialties, like general surgeons, urologists, oncologists, and bariatric surgeons, to overcome the contraindications of Palmer's point. The Jain point also acts as the main ergonomic working port, whereas Palmer's point becomes redundant after initial entry.

Renal Hilum Injury with Veress Needle

Introduction

Since the advent of laparoscopy, the ideal first-port entry technique has not yet been determined. Use of the Veress needle at Palmer's point, although safe in practice under skilled physicians, is not without risk of complications.

Case Description

A female patient with prior abdominal surgeries underwent a laparoscopic surgery for a nonmalignant indication. Intraoperative complications included hemodynamic instability and gross hematuria. The patient was ultimately stabilized, and imaging after the case revealed a hematoma formation around the left kidney with evidence of renal hilar injury.

Discussion

The laparoscopic surgeon must be aware that blind Veress needle entry has inherent risk for injury of retroperitoneal structures including the renal system. Particularly if hemodynamic instability is noted after abdominal entry at any site, physicians should have a low threshold for investigation, including by laparotomy if necessary.

Abdominal Wall Thickness at Palmer's Point and Distance to Adjacent Structures Across the Body Mass Index Spectrum

STUDY OBJECTIVE

Studies delineating left upper quadrant (LUQ) anatomy across a range of body mass indices are lacking. We aimed primarily to compare, between non-obese and obese women, abdominal wall thickness and the distance from the LUQ to key structures. Additionally, we aimed to characterize LUQ anatomy in underweight women.

DESIGN

A retrospective cohort study.

SETTING

A tertiary academic medical institution.

PATIENTS

Sixty women (30 non-obese, 30 obese) age 18 and older who underwent abdominal imaging from 10/1/2018 through 12/31/2018.

INTERVENTIONS

Computed tomography imaging of the chest, abdomen, and pelvis.

MEASUREMENTS AND MAIN RESULTS

Abdominal wall thickness at the LUQ was significantly greater in obese (4.3 ± 1.7 cm) as compared to non-obese patients (2.4 ± 1.7 cm) (p<.001), as were distances to all key structures (aorta, vena cava, spleen, stomach, pancreas, liver, left kidney, pelvis) (p≤.02). On average, all structures, with the exception of stomach and liver, were >10 cm (the length of a typical insufflation needle) away from the LUQ insertion point in obese women. In underweight women, the aorta, spleen, stomach, pancreas, and liver were all within 10 cm of the LUQ insertion point. Within the obese and non-obese group, abdominal wall thickness at the LUQ was significantly greater than at the umbilicus (p<.001). Body mass index (BMI) was more strongly correlated with abdominal wall thickness at the LUQ (r=0.84, p<.001) than at the umbilicus (r=.69, p<.001) (p=.007 for comparison).

CONCLUSION

This study highlights special anatomic considerations for LUQ access in obese and underweight patients. In obese women, abdominal wall thickness may be greater at this site than at the umbilicus and the liver and stomach remain within reach of an insufflation needle. The increased working distance from the LUQ to the pelvis in obese patients may necessitate specialized instruments if this site is used during surgery. In underweight women, the aorta, in addition to many other structures, is within reach of commonly used entry devices.

Transperitoneal Subcostal Access for Urologic Laparoscopy: Experience of a Large Chinese Center

Objective. To present our experience of using transperitoneal subcostal access, Palmer's point (3 cm below the left costal margin in the midclavicular line), and its right corresponding site, in urologic laparoscopy. Methods. We used Palmer's point and the right corresponding site for initial access in 302 urologic surgeries (62 cases with prior surgeries). The record of these cases was reviewed. Results. Success rate of initial access is 99.4%, and complication rate of puncturing is only 3.4% with no serious complication. In the cases with prior surgeries, there were only two cases with access complication on the right side (minor laceration of liver). For people with BMI more than 30 kg/m² (12, 3.9%), the success rate was also 100 percent. Conclusions. Palmer's point and the corresponding right location are feasible, effective, and safe for initial access in urologic laparoscopic surgeries. This entry technique should be used routinely in urologic laparoscopic surgeries.

Jain point: A new safe portal for laparoscopic entry in previous surgery cases

INTRODUCTION

The present study was performed to assess the safety and feasibility of a new laparoscopic entry site in cases suspected of adhesions due to previous surgery.

MATERIALS AND METHODS

It is a retrospective study undertaken at a tertiary care referral center for advanced gynecological laparoscopic surgery from January 2011 to December 2014.

RESULTS

In 624 patients with a history of previous abdominal surgeries, the laparoscopic entry site was through a newly devised point. It is a point in the left paraumbilical region at the level of umbilicus, in a straight line drawn vertically upward from a point 2.5 cm medial to anterior superior iliac spine. Intra-abdominal adhesions were found in 487 (78.0%) patients, and umbilical adhesions in 404 (64.7%) patients with past abdominal surgeries.

CONCLUSION

There were no significant entry-related, intra-operative, or postoperative complications with the use of this entry point. It is also suitable as a main working port during the course of surgery.