Laparoscopic Peritoneal Entry with the Reusable Threaded Visual Cannula

Complications in Laparoscopic Access in Standing Horses Using Cannula and Trocar Units Developed for Human Medicine

First cannulation is a critical manoeuvre in equine laparoscopy. This retrospective study aimed at the comparison of the frequency and type of complications detected when using different human laparoscopy devices for laparoscopic access in standing horses, and the influence of body condition in such complications. Forty-four procedures were included, and retrieved data comprised cannula insertion technique, body condition, and type and frequency of complications. Laparoscopic access techniques were classified into five groups: P: pneumoperitoneum created using Veress needle prior to cannulation; T: sharp trocar; D: direct access via surgical incision; V: Visiport optical trocar and H: optical helical cannula (OHC). In groups T, D, V and H, access was achieved without prior induction of pneumoperitoneum. Complications were registered in 13/44 procedures, of which retroperitoneal insufflation was the most common (6/13). Statistically significant association was found between the complication incidence and the type of access, with group D showing the highest complication frequency (80%) and group H the lowest frequency (0%). The majority of complications (9/13) were observed in overweight horses. We conclude that devices designed for human patients can be used for laparoscopic access in standing horses, with the use of OHC minimizing the appearance of complications, especially in overweight horses with OW.

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.

Complications related to entry techniques for laparoscopy in 159 dogs and cats

OBJECTIVE

To report the frequency and risk factors of complications related to 3 entry techniques for laparoscopy in small animals.

STUDY DESIGN

Single-institution retrospective case series.

ANIMALS

159 client-owned dogs and cats.

METHODS

Medical records were reviewed for dogs and cats undergoing laparoscopic surgery with carbon dioxide (CO₂ ) insufflation between 2006 and 2018. Data including entry site, entry technique, signalment, body conformation, complications, and operating surgeon/resident were analyzed by univariate regression analysis. Factors with P < .25 were included in multivariate regression analysis.

RESULTS

Complications occurred in 33 of 159 (21%) surgeries and were considered minor (CO₂ leaks, omental insufflation, repeated entry) in 30 of 33 (91%) cases. The Ternamian visual entry, modified Hasson, and Veress needle entry techniques were associated with complications in 7 (9%), 17 (26%), and 9 (60%) surgeries, respectively. Major complications occurred in 3 of 159 (2%) surgeries, in which entry-related hemorrhage prompted conversion to an open technique (2 [13%] entries with Veress needle) and 1 [1%] with the Ternamian visual). Entry location and entry technique remained significant in the final multivariate model. Complications were 11.7 times more likely after a paramedian entry than after a midline entry; the odds ratio of complications were 5 and 28 times higher after modified Hasson and Veress needle entries, respectively, than after Ternamian visual entry.

CONCLUSION

In this study, a Ternamian visual entry technique and midline entry site appeared associated with fewer complications than 2 other techniques.

CLINICAL SIGNIFICANCE

The findings in this study are preliminary, and superiority of any entry technique must be reevaluated in a prospective randomized controlled study.

Laparoscopic entry techniques: What is the controversy?

OBJECTIVE

To review reported complications related to the different laparoscopic entry techniques in the human and veterinary literature and describe the benefits and limitations of each technique.

STUDY DESIGN

Literature review of 57 peer-reviewed articles.

METHODS

An electronic database search identified human and veterinary literature describing complications related to entry technique during laparoscopy.

RESULTS

Open- and closed-entry techniques may result in trauma of abdominal organs or vasculature. During laparoscopy in man, injury to bowel and major vasculature is reported in 0.02% and 0.04% of procedures with open- or closed-entry techniques, respectively. Designs of Veress needles and trocar cannula assemblies have been developed to improve ease and safety. Early complications, defined as those observed at the time of port entry into the abdominal cavity, result from the puncture of a blood vessel leading to substantial visible hemorrhage. Late complications are detected 24 or 48 hours after surgery and result from the puncture of a loop of intestine that was not detected at the time of initial surgery. The major reasons for iatrogenic trauma in man are related to anatomical factors and the presence of adhesions. No explanation for cause of complications was identified for animals.

CONCLUSION

There is no consensus in the human or veterinary literature about the best entry technique for laparoscopy. The rate of complications related to entry technique in small animals is not known because the data are underreported.

CLINICAL SIGNIFICANCE

Complications related to entry techniques are expected in both man and animals. Improvements in techniques and equipment design are being developed to minimize risk.

Ultrarapid Induction of Hypothermia Using Continuous Automated Peritoneal Lavage With Ice-Cold Fluids: Final Results of the Cooling for Cardiac Arrest or Acute ST-Elevation Myocardial Infarction Trial

OBJECTIVES

Hypothermia (32-34 °C) can mitigate ischemic brain injury, and some evidence suggests that it can reduce infarct size in acute myocardial infarction and acute ischemic stroke. For some indications, speed of cooling may be crucial in determining efficacy. We performed a multicenter prospective intervention study to test an ultrarapid cooling technology, the Velomedix Automated Peritoneal Lavage System using ice-cold fluids continuously circulating through the peritoneal cavity to rapidly induce and maintain hypothermia in comatose patients after cardiac arrest and a small number of awake patients with acute myocardial infarction.

DESIGN

Multicenter prospective intervention study.

SETTING

Intensive care- and coronary care units of multiple tertiary referral centers.

MEASUREMENTS AND MAIN RESULTS

Access to the peritoneal cavity was gained using a modified blunt dilating instrument, followed by catheter placement. Patients were cooled to a temperature of 32.5 °C, maintained for 24 hours (cardiac arrest) or 3 hours (acute myocardial infarction) followed by controlled rewarming. Forty-nine patients were enrolled, and 46 patients completed treatment. One placement was unsuccessful (abdominal wall not breached), two patients were ultimately not cooled, and only safety data are reported. Average catheter insertion time was 2.3 minutes. Mean time to temperature less than 33 °C was 10.4 minutes (average cooling rate, 14 °C/hr). Median infarct size in patients who had coronary interventions was 16% of LV. No cases of stent thrombosis occurred. Survival in cardiac arrest patients with initial rhythm of ventricular tachycardia/ventricular fibrillation was 56%, of whom 82 had a complete neurologic recovery. This compares favorably to outcomes from previous studies.

CONCLUSION

Automated peritoneal lavage system is a safe and ultrarapid method to induce and maintain hypothermia, which appears feasible in cardiac arrest patients and awake patients with acute myocardial infarction. The shivering response appeared to be delayed and much reduced with this technology, diminishing metabolic disorders associated with cooling and minimizing sedation requirement. Our data suggest that ultrarapid cooling could prevent subtle neurologic damage compared with slower cooling. This will need to be confirmed in direct comparative studies.

Abdominal anatomy in the context of port placement and trocars

Although the anatomy of the human being has not changed, technical developments in operating materials and methods demand a simultaneous development in operative management. Developments in electronic and optical technologies permit many gynecological operations to be performed laparoscopically. One fundamental distinction between any other operating method and laparoscopy is the hurdle that the initial entry, whether with a needle, cannula, or trocar, is mostly performed blind. However, there is a risk that blind entry may result in vascular or organ damage. One of the difficulties associated with entry complications is that any damage may not be immediately recognized, leading to major abdominal reparative surgery, and at worst, a temporary colostomy. Therefore, the technical and operative quality of laparoscopic surgery begins with port placement and trocars. Visual access systems are available but are not yet widely used. The aim of this review was to introduce the different port placement and trocar systems as well as their correct and professional usage in correlation with the abdominal functional anatomy.