Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

Evaluation of the benefit of indocyanine green as an educational and practical tool for ureteral identification in laparoscopic pelvic surgery: a cross-sectional study

BACKGROUND

Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated.

METHOD

This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries.

RESULTS

No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory.

CONCLUSIONS

ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.

The relevance of reducing Veress needle overshooting

Safe insertion of the Veress needle during laparoscopy relies on the surgeons' technical skills in order to stop needle insertion just in time to prevent overshooting in the underlying organs. To reduce this risk, a wide variety of Veress needle systems were developed with safety mechanisms that limit the insertion speed, insertion depth or decouple the driving force generated by the surgeon's hand on the needle. The aim of this study is to evaluate current surgeons' perceptions related to the use of Veress needles and to investigate the relevance of preventing overshooting of Veress needles among members of the European Association of Endoscopic Surgery (EAES). An online survey was distributed by the EAES Executive Office to all active members. The survey consisted of demographic data and 14 questions regarding the use of the Veress needle, the training conducted prior to usage, and the need for any improvement. A total of 365 members residing in 58 different countries responded the survey. Of the responding surgeons, 36% prefer the open method for patients with normal body mass index (BMI), and 22% for patients with high BMI. Of the surgeons using Veress needle, 68% indicated that the reduction of overshoot is beneficial in normal BMI patients, whereas 78% indicated that this is beneficial in high BMI patients. On average, the members using the Veress needle had used it for 1448 (SD 3031) times and felt comfortable on using it after 22,9 (SD 78,9) times. The average years of experience was 17,6 (SD 11,1) and the surgeons think that a maximum overshoot of 9.4 (SD 5.5) mm is acceptable before they can safely use the Veress needle. This survey indicates that despite the risks, Veress needles are still being used by the majority of the laparoscopic surgeons who responded. In addition, the surgeons responded that they were interested in using a Veress needle with an extra safety mechanism if it limits the risk of overshooting into the underlying structures.

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis

OBJECTIVE

Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques.

DATA SOURCE

A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO.

METHODS

The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020.

RESULTS

Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD =  - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78).

CONCLUSION

There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review

OBJECTIVE

This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management.

DATA SOURCES

A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021.

METHODS OF STUDY SELECTION

All study types were included involving female patients of any age with gastric injury at laparoscopy for gynecologic indication.

TABULATION, INTEGRATION, AND RESULTS

A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae.

CONCLUSION

This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publications.