Principles of safe laparoscopic entry

Feasibility and safety of vNOTES for gynecological procedures in obese patients

INTRODUCTION

This study aimed to determine the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to treat benign and malign gynecological conditions in obese patients.

MATERIAL AND METHODS

We analyzed data from 79 obese patients with a body mass index (BMI) > 30 Kg/m2 operated by vNOTES for gynecological conditions between May 2020 and April 2023. The primary outcome was the feasibility of performing the surgery as initially planned. Data were presented for subgroups of patients with obesity class I (BMI 30.1 - 34.9 Kg/m2), class II (BMI 35.0 - 39.9 Kg/m2), and class III (BMI ≥ 40.0 Kg/m2).

RESULTS

Patients presented obesity class I in 39 cases (49.4 %), class II in 27 cases (34.2 %), and class III in 13 cases (16.4 %). Fifty-two patients (65.8 %) underwent vNOTES hysterectomy, 26 patients (32.9 %) underwent procedures limited to the adnexa, and 1 patient (1.3 %) underwent myomectomy. The conversion rate was 0 %, 11.1 %, and 7.7 % in obesity class I, II, and III, respectively. Intraoperative bladder injury was observed in 1 case (1.3 %) and rectal serosal tear in 2 cases (2.5 %). Postoperatively, we observed 3 cases (3.8 %) of wound infection, 2 cases (2.5 %) of cystitis, and 1 case (1.3 %) of deep vein thrombosis.

DISCUSSION

This study demonstrated the feasibility and safety of performing gynecological vNOTES procedures in obese patients. However, obesity could be associated with longer and more complex interventions, especially in obesity class II and III patients.

Injuries incurred from minimally invasive access for abdominal surgery

BACKGROUND

Injuries during initial port placement in minimally invasive abdominal surgery are rare but can cause major morbidity. We aimed to characterize the incidence, consequence, and risk factors for injury occurring on initial port placement.

METHODS

This is a retrospective review of a General Surgery quality collaborative database with supplementary input from the Morbidity and Mortality conference database at our institution between 6/25/2018 and 6/30/2022. Patient characteristics, operative details, and postoperative course were assessed. Cases with an injury on entry were compared to cases without an injury to identify risk factors for injury.

RESULTS

8844 minimally invasive cases were present between the two databases. Thirty-four injuries (0.38%) occurred during initial port placement. Seventy-one percent of injuries were bowel injuries (full or partial thickness) and the majority (79%) of injuries were recognized during the index operation. Median surgeon experience for the cases with an injury was 9 years (IQR 4.25-14.5) compared to 12 years of experience for all surgeons contributing to the database (p = 0.004). Previous laparotomy was also significantly correlated with the rate of injury on entry (p = 0.012). There was no significant difference in the rate of injury based on method of entry (cut-down: 19 (55.9%), optical entry without Veress: 10 (29.4%), Veress followed by optical entry: 5 (14.7%), p = 0.11). BMI > 30 kg/m² (injury: 16/34 vs no injury: 2538/8844, p = 0.847) was not associated with an injury. Fifty-six percent (19/34) of patients with an injury on initial port placement required laparotomy at some point in their hospital course.

CONCLUSIONS

Injuries are rare during initial port placement for minimally invasive abdominal surgery. In our database, history of a previous laparotomy was a significant risk factor for an injury and appears to be more consequential than commonly implicated factors such as technique, patient body habitus, or surgeon experience.

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.

Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications

A trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. A retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2014, and June 30, 2020, identified 268 events. Internal organ and vascular injuries accounted for 81.0% of events; trocar site skin integrity injuries, bleeding/hemorrhage, and hernias accounted for 17.2% of events; and vasovagal responses accounted for 1.9% of events. Internal injuries occurring during the initial insertion of the trocar, Veress needle, or incision in preparation for a trocar insertion was reported in 64.5% of events. Adhesions were identified in 13.5% of internal injury events. Many internal injury events identified a single injury; however, in 17 instances patients sustained two trocar-related injuries. Conversion to open surgery, return to the operating room during the same admission, postoperative intensive care unit admission, ambulatory surgical facility transfer to a hospital, readmission, postdischarge return to the operating room, and death are outcomes identified in the event reports.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

OBJECTIVE

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

TARGET POPULATION

All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

OUTCOMES

Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

EVIDENCE

We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

INTENDED AUDIENCE

Surgeons performing laparoscopic gynaecological surgery.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Demonstration of Safe Entry Techniques for Laparoscopy

STUDY OBJECTIVE

To demonstrate different techniques, and detail the considerations for obtaining primary laparoscopic access in gynecologic surgery.

DESIGN

Video demonstration of the techniques with narrated discussion of each method.

SETTING

The methods for primary entry in laparoscopy vary by location and technique [1,2]. There are inherent risks with any mode of primary entry, and the risks are also specific to each technique [3-6]. The choice for primary entry depends on the patient's anatomy, surgical history, pathology, and surgeon preference [1,2].

INTERVENTIONS

This video reviews considerations for choosing the safest entry point and tips for proper entry technique [4,7-10]. The entry sites reviewed include the umbilicus, left upper quadrant, right upper quadrant, and supraumbilical [11]. The entry technique can be either open (Hasson), closed (Veress), or by direct laparoscopic visualization [9,10,12-14].

CONCLUSION

No single laparoscopic entry technique is superior [3]. The safest and most successful entry method will vary by case characteristics and surgeon training.

Uso de cânula rígida com rosca e endoscópio flexível para videolaparoscopia de acesso único em equinos em estação

RESUMO Com o objetivo de promover, por meio de acesso único e com o uso de endoscópio flexível, ampla exploração da cavidade peritoneal de equinos em estação, foi concebida uma cânula laparoscópica para dar sustentação ao endoscópio e possibilitar o acesso sob visualização. O procedimento foi realizado a partir da fossa paralombar. Após pequena incisão cutânea, o endoscópio foi inserido na cânula e os músculos e o peritônio foram divulsionados mediante rotação da cânula. Logo depois da perfuração do peritônio, foi realizada a exploração da cavidade e a identificação das estruturas. Em seguida à exploração do lado ipsilateral ao acesso, realizou-se a transposição do conjunto cânula/endoscópio ventralmente à porção caudal do cólon descendente, seguida de exploração do lado contralateral. Concluída a técnica, foi executado, para fins de comparação, o mesmo procedimento por meio da fossa paralombar contralateral. Foi possível a transposição do conjunto cânula/endoscópio para o lado contralateral ao acesso em todos os procedimentos. Também foi possível a identificação da maioria das estruturas abdominais tanto pelo acesso esquerdo quanto pelo direito. A abordagem por acesso único mostrou-se viável para a exploração ampla da cavidade peritoneal, demonstrando ser uma alternativa à técnica laparoscópica convencional.

Prevention and management of bowel injury during gynecologic laparoscopy: an update

PURPOSE OF REVIEW

The current article aims to briefly review recent literature on bowel injury in gynecologic surgery with a focus on minimally invasive techniques, strategies for prevention, and management of injury.

RECENT FINDINGS

Recent reviews describe a low incidence of bowel injury that is likely affected by low rates of reporting and inconsistent definitions. The major risk factor for bowel injury is adhesive disease, and assessment and prevention techniques for the presence of adhesive disease are evolving. When bowel injury occurs, prompt diagnosis and intraoperative repair yields more favorable outcomes than delayed diagnosis. Repair can be performed by a gynecologic surgeon, with or without the help of a consultant depending on the extent of the injury and surgeon comfort.

SUMMARY

Bowel injury is a potentially catastrophic complication in gynecologic surgery, but its rarity presents a challenge in research. A high index of suspicion and meticulous surgical technique are the cornerstones of managing a bowel injury.

Laparoscopy during pregnancy: Case report and key points to improve laparoscopic management

CASE REPORT

A 34-year-old woman in her 19th week of gestation was admitted to the Emergency Department of our hospital for acute abdominal pain. The patient was diagnosed with haemoperitoneum. Laparoscopy was performed and revealed acute bleeding from a crumbly superficial uterine vascular network. Haemostasis was achieved and both mother and foetus recovered well after surgery. A caesarean section was performed at 38 weeks, delivering a healthy newborn and revealing that the pregnancy had developed in a rudimentary hemiuterus. Laparoscopy during pregnancy is safe and feasible and can be performed in any trimestre of pregnancy with no differences in perinatal outcomes but, as intervention complexity increases with gestational age, laparoscopy during pregnancy should be performed by experienced surgeons To minimise surgical risk several recommendations should be taken into account: gravid patients should be positioned in a left-tilted supine position, trocar placement should be adjusted to uterine size and gas insuflattion of 10-15mmHg can be used.

Direct Laparoscopic Trocar Insertion: Lessons Learned from Nine Litigated Cases

STUDY OBJECTIVE

To report circumstances and clinical and medicolegal outcomes of 9 litigated cases associated with direct trocar insertion (DTI) injuries to the bowel (7 cases) and major vessel (2 cases) during primary laparoscopic access.

DESIGN

A case series from 1990 through 2015 (Canadian Task Force Classification II-2).

PATIENTS

Nine litigated cases.

INTERVENTIONS

A retrospective review of medical and legal records of litigated cases in Canada reviewed by the primary author (G.A.V.).

MEASUREMENTS AND MAIN RESULTS

The average and range of age and body mass index of the women were 31 years (range, 14-65 years) and 25 kg/m² (range, 20-35 kg/m²), respectively. Indications for laparoscopy included diagnostic (4), laparoscopically assisted vaginal hysterectomy (3), pelvic mass (1), and laparoscopic cholecystectomy (1). DTI was performed with 10-mm trocars (5 shielded, 1 reusable, and 3 unknown). Two complications were experienced by patients of the same male surgeon (cases 2 and 9). Injuries included the small bowel (4 cases), colon (3 cases), and major vessel (2 cases). Vascular injuries resulted in permanent brain damage in 1 and near loss of limb in the other; litigation was favorable to the plaintiff in both cases. All bowel injuries presented with signs and symptoms of peritonitis within 3 postoperative days (PODs) (5 patients on POD 1, 1 patient on POD 2, and 1 patient on POD 3); however, only 2 cases were acted upon and remedied with favorable clinical and medicolegal outcomes. A delayed exploratory laparotomy resulted in significant adverse clinical outcomes (ileostomy/colostomy in 4 patients, multiple surgeries in 7 patients, and 1 death), and in all delayed actions, the medicolegal outcomes were favorable to the plaintiff.

CONCLUSION

During laparoscopic primary peritoneal access using the DTI technique, inadvertent intra-abdominal injury may be significant when major vessels are involved and when intervention is delayed in bowel injuries. These result in significant adverse clinical complications and may provoke higher litigation with more favorable outcomes for the plaintiff.