Comparative study on complications and difficulties in laparoscopy in female genital tuberculosis cases versus non-tuberculosis cases

BACKGROUND AND OBJECTIVE

Female genital tuberculosis (FGTB) is an important type of extrapulmonary tuberculosis (TB) associated with morbidity especially infertility in developing countries. Laparoscopy may be difficult and hazardous in FGTB. The aim of the study was to observe the difficulties and complications of laparoscopy in FGTB cases.

MATERIALS AND METHODS

It was a prospective study over 12 years' period on 412 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling for acid-fast bacilli (AFB) microscopy, culture, polymerase chain reaction (PCR), gene Xpert (last 212 cases) and histopathological evidence of epithelioid granuloma. Another 412 cases of diagnostic laparoscopy in the absence of FGTB performed during same time were taken as controls from the pool of non-TB cases. Various difficulties and complications were noted in both groups and statistical analysis was done.

RESULTS

Mean age, parity, body mass index and duration of infertility were 26.8 versus 25.4 years, 0.32 versus 0.28, 23.15 versus 25.28 Kg/m 2 and 4.15 versus 5.12 years, respectively. Primary and secondary infertility was seen in 78.6% and 20.38% of cases in the study group and 74.75% and 25.24% in the control group, respectively. Endometrial biopsy showed AFB microscopy in 5.3%, culture in 6.3%, epithelioid granuloma in 15.77% and on peritoneal biopsy granuloma in 6.55%, positive PCR in 368 (89.32%) and positive gene Xpert in 38 out of 212 (17.92%, out of last 212 cases). Definite findings of FGTB were seen in 171 (41.50%) cases. Probable findings of FGTB were seen in 241 (58.49%) cases. Various complications were difficulty in the creation of pneumoperitoneum or insertion of trocar and cannula in 16.74% and 13.10% of cases as compared to 1.94% and 1.69% in the control group. Excessive bleeding was seen in 5.09% versus 0.97% cases, respectively. Various injuries observed were bowel injury in 1.69% versus 0.24% cases (small bowel in 1.21% vs. 0.24%, large bowel in 0.48% vs. 0.1%), while bladder injury was seen in 0.97% versus 0.24% cases, subacute intestinal obstruction was seen in 5.8% versus 0.72% cases respectively while flare up of TB was seen in 5.09% versus 0% in cases and controls, respectively. Wound infection was seen in 8.48% versus 1.25% cases, respectively.

INTERPRETATION AND CONCLUSION

FGTB is associated with increased complications and difficulties as compared to laparoscopy in other cases.

MRI enhances the understanding of critical anatomy during primary laparoscopic port placement

Despite the majority of laparoscopic visceral injuries occurring with primary entry, high-fidelity training models are lacking. Three healthy volunteers underwent non-contrast 3T MRI at Edinburgh Imaging. A direct entry 12mm trocar was filled with water to improve MR visibility, placed on the skin at entry points, then images were acquired in the supine position. Composite images were created, and distances from the trocar tip to the viscera were measured, demonstrating anatomical relationships during laparoscopic entry. With a BMI of 21 kg/m2, gentle downward pressure during skin incision or trocar entry reduced the distance to the aorta to less than the length of a No. 11 Scalpel blade (22mm). The need for counter-traction and stabilisation of the abdominal wall during incision and entry is demonstrated. With a BMI of 38 kg/m2, deviating from the vertical angle for trocar insertion can result in the entire trocar shaft being placed within the abdominal wall without entering the peritoneum, creating a 'failed entry.' At Palmer's point distance between the skin and bowel is only 20mm. Ensuring the stomach is not distended will minimise gastric injury risk. The use of MRI to provide visualisation of the critical anatomy during primary port entry allows the surgeon to gain better understanding of textually described best practice techniques.

Preferred technique of creating pneumoperitoneum for laparoscopy by pediatric surgeons

Background

Minimally invasive pediatric surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Creation of pneumoperitoneum is a must for any laparoscopic procedure. Different pediatric surgeons have their individual preferences regarding the technique to create pneumoperitoneum prior to laparoscopy. The aim of this study was to evaluate the preference of technique for the creation of pneumoperitoneum in pediatric laparoscopy among Indian Pediatric Surgeons. The study was designed by communication with members of the Indian Association of Pediatric Surgeons using a predefined questionnaire. 180 pediatric surgeons responded to the survey. The respondents included pediatric surgeons in institutional and private practice. The reasons behind their preference were enumerated and evaluated.

Results

Seventy-one percent of pediatric surgeons preferred the primary open technique for the creation of pneumoperitoneum. Seventeen percent exclusively used Veress needle whereas 12% were using both techniques varying from patient to patient.

Conclusion

Creation of pneumoperitoneum remains an important safety issue for all pediatric surgeons. Pediatric Surgeons in India prefer using the primary open technique for the creation of pneumoperitoneum for laparoscopic surgery.

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.

Laparoscopic versus Open Ovariectomy in Bitches: Changes in Cardiorespiratory Values, Blood Parameters, and Sevoflurane Requirements Associated with the Surgical Technique

The aim of this study was to examine the cardiorespiratory and blood changes associated with pneumoperitoneum (PNP) in laparoscopic ovariectomy (LAP Ove), as well as sevoflurane requirements, comparing them to those determined in open surgery (LPT Ove). The study was performed in 16 bitches submitted to LAP or LPT Ove. The cardiorespiratory and end-tidal sevoflurane concentration values were recorded as follows: at the beginning of surgery (T1), after the right ovary resection (T2), after the left ovary resection (T3), and after surgical closure (T4). Blood samples were taken before and after PNP. Among the cardiorespiratory parameters, no differences were observed in the values of end-tidal CO2, minute volume, and heart rate. In the LAP Ove group, a significant increase in inspiratory pressures and a decreased compliance were identified at T2 and T3. Significant higher arterial pressure values were observed in both groups at T2 and T3, with this increase especially marked at T2 in the LPT Ove group. Sevoflurane requirements were significantly higher in the LPT group during ovarian resection. Finally, in terms of the hematochemical parameters, statistical differences were recorded between pre- and post-operative assessments, but not between both surgical groups. The pathophysiological effects associated with PNP seemed to be transient and well-tolerated by healthy dogs.

Jain point: an alternate laparoscopic non-umbilical first blind entry port to avoid vessel, viscera, adhesions and bowel (VVAB)

The Jain point entry is based on the concept of non-umbilical entry to avoid sudden catastrophic injury to major retroperitoneal vessels, viscera, adhesions and bowel which could happen before the start of procedure by blind umbilical entry. To study the safety and efficacy of a novel first non-umbilical blind entry port. Tertiary referral centre for advanced laparoscopic surgeries with active training and fellowship programs. A large retrospective study of 7802 cases done at Vardhman Infertility & Laparoscopy Centre from January 2011 to December 2020. In all cases, first blind entry was by veress needle and 5 mm trocar and telescope through a non-umbilical port, The Jain point, irrespective of BMI, large masses, lax abdomen, previous surgery and complex situations. Patients’ demographic profile, types of surgeries performed and entry-related complications were recorded and analysed. Mean age of patients was 33 years with BMI ranging from 12.66 to 54.41 kg/m². Thus, Jain point can be applicable for all ranges of BMI, all types of surgeries from simple to complex and large masses. Entry related minor complications were in 3.4% cases while major complication involving bowel occurred in one case. No case of injury to major retro-peritoneal vessel was seen. Jain point entry is a novel, first blind 5 mm non-umbilical, entry technique in a variety of surgeries and previous scars and patients with wide range of BMI. It has a short learning curve and continues as main ergonomic working port.

Psychomotor skills development for Veress needle placement using a virtual reality and haptics-based simulator

PURPOSE

Veress needle (VN) insertion, if not correctly performed, could cause severe injuries to intra-abdominal organs and vessels. Therefore, cognitive and psychomotor skills training is needed. Virtual reality (VR) and haptic technologies have the potential to offer realistic simulations.

METHODS

We developed a novel VR and haptic surgical simulator for VN insertion to teach trainees how to correctly puncture the abdominal wall, experiencing realistic tactile sensations throughout the simulation. The simulator allows for both procedural and realistic training. We released two different versions: the first using the OpenHaptics[Formula: see text] (OH) Toolkit and the second exploiting CHAI3D. We evaluated the learning effect using different performance indexes (time to perform the procedure, error in insertion angle, number of undesired contacts with organs) in an insertion task for both experienced urologists and students.

RESULTS

A general improvement of the chosen performance indexes was registered in the second repetition of the task for both groups. From the questionnaires, the simulator leveraging OH provides the trainee with a more precise haptic feedback, whereas the one exploiting CHAI3D allows them to perform the procedure more easily thanks to the better visualization of the virtual environment. The results proved that the participants appreciated both implementations, and the System Usability Scale (SUS) test resulted in a "good" usability.

CONCLUSION

The haptics-based and VR simulator has shown the potential to be an important resource for the basic urological training in obtaining the pneumoperitoneum and improving the acquisition of the necessary psychomotor skills, allowing for extended and more effective training without compromising patient safety.

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.

Presentation of an open entry technique for laparoscopy through a congenital defect in the umbilical fascia

OBJECTIVE

We present and describe a modification of the Hasson open entry technique to gain access to the abdominal cavity for laparoscopy in which a congenital defect in the umbilical fascia is identified for entry into the peritoneum and insertion of the primary port.

METHODS

A single centre, prospective, observational, pilot study has been conducted with no change in clinical practice. Data regarding the success of the technique, time to laparoscope insertion, complications and patient risk factors were collected and presented.

RESULTS

The team enrolled 114 patients that had the St Helier technique attempted for entry in the abdominal cavity. Entry was achieved for all patients. The technique had 82.5 % success rate while this reduced to 65 % in patients with previous laparoscopies. The mean time to insertion of the laparoscope was 220 s, and there was no significant difference in success with variation in BMI. We recorded no minor or significant intra-operative complications. The superficial wound infection rate was 2.6 % with no other postoperative complications identified at 6-week follow-up.

CONCLUSIONS

The presented technique is a safe and successful method of laparoscopic entry with a presumed shorter time until laparoscope insertion than other techniques used. The absence of complications could be attributed to the avoidance of sharp dissection of the umbilical fascia. The less invasive nature could reduce risks of hematoma, infection or hernia that are associated with the standard entry techniques used. Formal studies of long-term outcomes are required, as well as evaluating use in emergency and contaminated cases.

No. 193-Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT.

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.

Primary unilateral not complicated inguinal hernia: our choice of TAPP, why, results and review of literature

BACKGROUND

Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair.

METHODS

The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques.

RESULTS

According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP.

CONCLUSION

Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

Laparoscopic Entry Technique Using a Veress Needle Insertion with and without Concomitant CO2 Insufflation: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare the time and number of attempts needed for successful Veress needle entry during laparoscopic surgery using concomitant versus subsequent CO₂ insufflation approaches.

DESIGN

Randomized controlled trial.

SETTING

University teaching hospital.

PATIENTS

One hundred consecutive patients scheduled for laparoscopic surgery by 2 high-volume laparoscopic surgeons were screened and randomized, and 95 of these were included in the final analysis. Ninety (45 in each group) was the precalculated priori number of patients needed to detect a 50% difference in the time (seconds) to obtain adequate insufflation with 90% power and alpha of 5%.

INTERVENTIONS

Patients were randomized to either Veress needle entry with concomitant (Con) or subsequent (Sub) CO₂ insufflation.

MEASUREMENTS AND MAIN RESULTS

Forty-six patients were randomized to the Con group and 49 to the Sub group. Patient age, body mass index, prior surgical history, presence of adhesions, and type of procedure performed were similar between both groups. The median time required for adequate insufflation in the Con group was 103.5 seconds (Q1-Q3, 80.0-130.0) compared with 113.0 seconds (Q1-Q3, 102.0-144.0) in Sub group (p = .16). Approximately 89% (95% confidence interval, 80.1%-98.1%) of patients in Con group achieved successful entry in the first attempt compared with only 67% (95% confidence interval, 54.2%-80.0%) in Sub group (p = .01). The incidence of preperitoneal insufflation and failed entry was comparable between the 2 groups. No patient developed solid organ, visceral, or vascular injuries; gas embolism; or case conversion to laparotomy in relation to the Veress needle entry technique.

CONCLUSION

Veress needle entry with concomitant CO₂ insufflation was associated with a higher rate of successful entry during the first attempt of Veress needle insertion. The total time required for insufflation and rates of complications between the 2 techniques were similar.

A review of the open laparoscopic Hasson technique and retrieval of adnexal specimen via umbilicus

Laparoscopic entry techniques vary amongst surgeons and gynaecologists, with gynaecologists favouring Veress needle entry. Recent RCOG/BSGE recommendations have recommended retrieval of ovarian masses via the umbilical port with resultant less postoperative pain and a faster retrieval time than with retrieval through lateral ports of the same size. This is a prospective observational study reviewing the Hasson entry technique and the introduction of retrieval of specimens via the umbilicus in patients scheduled for a laparoscopy procedure at our day surgery unit. We found no immediate or major surgical complications and all specimens were successfully retrieved through the umbilicus. Pain scores were low. We recommend the technique for extirpative gynaecological surgery. Impact Statement This study confirms that conversion from the closed Veress to the open Hasson technique is achievable in a university hospital setting. Operator confidence during the learning phase is enhanced by the use of ultrasound to locate and measure the depth of the umbilical ligament. Retrieval of benign adnexal specimens through the umbilicus was very satisfactory.

Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy

BACKGROUND

The 2 main challenges of laparoscopic cholecystectomy are primary peritoneal access and safe identification, ligation, and division of the cystic duct and cystic artery.

PATIENTS AND METHODS

This is a 13-year period retrospective study from January 2000 to December 2012. All the operations were performed by 1 surgeon and all the data were collected from the hospitals archive. A total of 929 laparoscopic cholecystectomies were performed for symptomatic cholelithiasis. The first author was involved in all the operations either by performing or assisting in them. The open access (OA) technique was used in all cases for the creation of pneumoperitoneum. After establishing the pneumoperitoneum, the "critical view of safety" (CVS) technique was used to ligate and divide the cystic duct and cystic artery. When the OA was not possible or CVS was not feasible, the operation was converted to open.

RESULTS

Successful establishment of pneumoperitoneum with OA was possible in 911 of 929 (98.06%) patients and CVS was achieved in 873 patients (95.82%). In 18 patients the operation was converted to open because of dense adhesions not permitting the establishment of the pneumoperitoneum. No intraoperative or postoperative complications occurred in these patients. No bile duct injury occurred in this series. Postoperative complications were recorded in 19 patients (2.04%). Five patients had bleeding from port sites, 12 patients had wound infection at the umbilical incision, and 2 patients developed subhepatic collections, which were drained percutaneously under computed tomographic guidance.

CONCLUSIONS

In this series of laparoscopic cholecystectomies, we used the "open access" technique to create pneumoperitoneum and we obtained the "critical view of safety" for the identification of the cystic duct. Our results show that this approach is the safest way to perform and teach laparoscopic cholecystectomy.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes

BACKGROUND

Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema.

METHODS

From January 2012 to January 2013, 10 consecutive female patients, average age 54.8 years, with International Society of Lymphology stage II-III extremity lymphedema refractory to conservative management were included. Five patients had upper limb breast cancer-related lymphedema and five patients had lower limb pelvic cancer-related lymphedema. All patients underwent laparoscopic harvest of the right gastroepiploic lymph node flap, transferred to the wrist and ankle as recipient sites. Flaps were covered with a small skin graft taken from the thigh. Perioperative assessment included physical exam, photography, circumference measurements, CT scans, lymphoscintigraphy, and Lymphedema Quality of Life (LYMQOL) questionnaire. Clinical and CT evaluation of donor-site morbidity were performed.

RESULTS

The flap survival rate was 100%, with a mean harvest time of 32 minutes and total operating time of 164 minutes. One case required regrafting for skin graft loss. The mean limb reduction rate was 39.5% at a mean follow-up of 14.7 months. Perioperative lymphoscintigraphy demonstrated transferred lymph node viability and lymphatic transport improvement. LYMQOL showed a 2.6-fold quality-of-life improvement (P < 0.01). No donor-site morbidity was encountered.

CONCLUSIONS

The use of the laparoscopically harvested right gastroepiploic lymph node flap may be a safe technique that improves limb measurements and quality of life in extremity lymphedema patients. © 2015 Wiley Periodicals, Inc. Microsurgery 37:197-205, 2017.

Comparison of two entry methods for laparoscopic port entry: technical point of view

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

New nomogram for safe laparoscopic entry to reduce vascular injury

A nomogram is developed to determine the length of Veress needle that could be safely inserted to achieve pneumoperitoneum to reduce the risk of vascular injury during laparoscopic entry. Axial images of magnetic resonance imaging (MRI) were used to measure the vertical distance between umbilicus and retroperitoneal vessels (STR). This distance was correlated with body mass index and a nomogram was developed to exactly measure the safe distance for the length of Veress needle insertion. The fitted equation was STR (skin to rectus sheath) = 31.6 + 3.952 × BMI with adjusted R(2) = 94.5%. The abdominal cavity depth showed a correlation with adjusted R(2) = 84.2%. This showed a significant relation between body mass index and prediction of cavity depth. Using the mean regression line for STP (skin to peritoneum), a safe insertion distance was identified and a nomogram developed which can be used to objectively predict the depth of the peritoneal cavity.

Risks associated with laparoscopic entry: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

The aim of these recommendations of the French National College of Gynaecologists and Obstetricians was to focus the surgeon's attention on those aspects which could allow him/her to prevent, or at least limit, the incidence of these serious complications, in the absence of a previous laparotomy or specific risk factors (obesity, gauntness, large pelvic mass or pregnancy), four widely evaluated techniques can be used in a first line approach (Grade B): blind trans-umbilical technique following creation of pneumoperitoneum with a needle, open laparoscopy (Hasson technique), left upper quadrant entry (pneumoperitoneum and insertion of the first trocar) and direct trans-umbilical trocar with no prior pneumoperitoneum. The currently existing trials do not allow one or another of these techniques to be preferred. Radially expanding insertion systems and optical trocars cannot be recommended as a first-line approach, as a consequence of their currently insufficient degree of evaluation (Grade C). Trans-umbilical (blind or open) laparoscopic entry in a slim woman must be associated with care, as a result of the proximity of the large vessels (Grade B). If a blind trans-umbilical insertion technique is decided upon, one option can be to insufflate into the left upper quadrant (professional consensus). In the case of a previous midline laparotomy, whatever the technique used, initial entry is recommended at a distance from the scars (Grade B). It is recommended to carry out micro-laparoscopy in the LUQ, because this is the most completely evaluated technique for this indication (Grade C). One option is to use open laparoscopy at a distance from the existing scars (professional consensus). During pregnancy, the insertion position of the first laparoscopic trocar will need to be adapted according to the volume of the uterus (Grade B). Starting from 14WG, trans-umbilical Veress needle insufflation is contraindicated (Grade C). Two trocar insertion techniques are thus recommended: open laparoscopy (using the trans-umbilical or supra-umbilical routes, depending on the volume of the uterus) or micro-laparoscopy via the left upper quadrant (Grade C). After the second quarter of pregnancy, with laparoscopy the patient will need to be placed on a table inclined towards her left side, in order to minimize compression of the inferior vena cava (Grade B). In the case of laparoscopy during pregnancy, the insufflation pressure must be maintained at a maximum of 12mmHg (Grade B). After 24WG, if laparoscopy is performed, it is recommended to apply open laparoscopy, above the level of the umbilicus (professional consensus). Patients must be informed of the risks inherent to the insertion of trocars during laparoscopy (vascular, bowel or bladder injury) (Grade B). The more benign the pathology requiring an operation, the more detailed the supplied information must be, including that concerning rare but serious complications (Grade B).

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years

BACKGROUND

Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued.

METHODS

Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed.

RESULTS

In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries.

CONCLUSION

Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.

Laparoscopic entry: a review of techniques, technologies, and complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Effect of body habitus and parity on insufflated CO2 volume at various intraabdominal pressures during laparoscopic access in women

STUDY OBJECTIVE

To determine height, weight, body mass index (BMI), parity, and age effect on the volume of CO2 pneumoperitoneum during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

PATIENTS

From January through June 2004, 100 healthy women underwent operative laparoscopic surgery consecutively by the senior author (GAV). Indications were: chronic pelvic pain (CPP, n = 66), pelvic mass (n = 7), CPP and pelvic mass (n = 4), infertility (n = 23). Median (range) height, weight, BMI, parity and age were 1.65 m (1.45-1.85 m), 70 kg (43-118 kg), 25.5 kg/m2 (17-39 kg/m2), 1.1 (0-5), and 34 years (19-58 years), respectively.

INTERVENTIONS

While in supine position, patients received general endotracheal anesthesia and muscle relaxants. Pneumoperitoneum was established by reusable Veres needle. The insufflated CO2 volume was serially recorded at intraperitoneal insufflation pressures (IPIPs) of 10, 15, 20, 25, and 30 mm Hg. The primary 10-mm trocar was introduced at IPIP of 30 mm Hg. Upon entering the peritoneal cavity, the abdominal contents were visualized with the laparoscope to ensure there was no injury, and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg before switching the patient to the Trendelenburg position.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) insufflated CO2 volumes at 10, 15, 20, 25, and 30 mm Hg were 1.7 (0.74) L, 3.1 (0.9) L, 3.96 (1.05) L, 4.42 (1.1) L and 4.72 (1.14) L, respectively. Using multivariate analysis, we demonstrated that at 20 to 30 mm Hg the insufflated CO2 volume correlated positively with the height, weight and BMI of women. Parity correlated positively at all pressures. There was no correlation with age at any pressure.

CONCLUSIONS

Higher CO2 volume is required to establish appropriate pneumoperitoneum in tall, overweight, and parous women at 20 to 30 mm Hg. Setting the IPIP at 20 to 30 mm Hg before primary trocar insertion eliminates the need to monitor CO2 insufflated volume regardless of women's age, parity, and body habitus.

Safe techniques for abdominal access and wound closure in laparoscopic surgery

Laparoscopic surgery requiring tissue morcellation was performed on 66 consecutive patients, using open laparoscopy for primary entry and the SECURE cone technique for accessing the port of mechanical morcellation. Thirty-six patients had laparoscopic myomectomy and 30 had supracervical laparoscopic hysterectomy. In all instances, abdominal entry was accomplished under visual control through a minilaparotomy incision, or using telescopic visualisation. The surgical wound was closed in two layers. The first layer consisted of the fascia at the primary site and the bulk of the abdominal wall at the morcellation site. The skin was approximated loosely. Although no complications were related to the open laparoscopy or SECURE cone techniques, most patients complained of mild to moderate postoperative discomfort related to the SECURE cone site. The discomfort was ameliorated when the bulk closure stitch was tied less tightly. Open laparoscopy and the SECURE cone methods represent safe techniques for primary and secondary abdominal access and wound closure in surgery.

Laparoscopic surgery

The generic advantages of avoiding a large laparotomy incision are now well established. For the patient, a laparoscopic procedure is invariably less painful, and recovery and return to full normal activities is more rapid. There are also significant gains in short-term quality of life measures associated with the laparoscopic approach. For the surgeon, improved visualisation offers the opportunity of more precise and accurate surgery. These advantages are usually offset by longer operating times, the use of complex and expensive equipment, and the possibility of new types of complications and increased risk of standard operative morbidity. The aim of this chapter is to identify areas of general technique in which the risks associated with laparoscopic surgery can be minimised while retaining all the advantages of the approach. This is being achieved partly by improved and simplified instrumentation, partly by refinement in techniques, and partly by an increasing awareness of the potential pitfalls of the approach and by adopting strategies to avoid these problems. The majority of gynaecological procedures are already performed endoscopically and all gynaecologists who operate will need to become proficient in these techniques. This chapter outlines techniques for safe laparoscopic entry and safe bipolar diathermy techniques, and describes how to undertake some of the simpler laparoscopic procedures; the evidence supporting these approaches is also presented. Surgical proficiency in safe laparoscopic entry and laparoscopic tubal surgery should lead to the confidence to then undertake more complex procedures.

Primary access-related complications with laparoscopy: comparison of blind and open techniques

BACKGROUND

Severe or fatal complications attributable to gas embolus, major vascular injury, or visceral injury are rare but have been reported after blind access to the abdominal cavity in laparoscopy. The open access technique has been introduced with the aim to reduce these injuries. This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods.

METHODS

Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 2,297 patients treated using blind access between 1992 and 1996 were compared with 2,066 patients treated using open step-by-step access between 1999 and 2001 regarding access-related complications. An accreditation program for both techniques was mandatory for the 67 surgeons involved.

RESULTS

No case of gas embolus or major vascular injury was seen in either group. Four cases of visceral injuries (0.17%) in the blind access group and one case (0.05%) in the open group were seen (p = 0.337). All the injuries were recognized and repaired intraoperatively with no further postoperative complications.

CONCLUSION

Our educational efforts to make both techniques as safe as possible were successful, as evidenced by a minimum of access-related complications. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy.

Safe entry techniques during laparoscopy: Left upper quadrant entry using the ninth intercostal space—A review of 918 procedures

Surgeons performing sophisticated endoscopic operations must be well versed in alternate laparoscopic access methods to address evolving patient expectations and safety requirements. The safety of left upper quadrant laparoscopic entry in patients with prior surgeries and abdominal adhesions was evaluated. Laparoscopic surgery was performed for various indications on patients with prior surgical scars and anticipated risk of adhesions at the primary umbilical port site. All laparoscopies performed from July 1998 through June 2004 were analyzed. Of the 918 laparoscopies, 504 patients (54.9%) were found to have involvement of their umbilicus with adhesions that could have affected the traditional umbilical primary port entry. Left ninth intercostal space was used for Veres needle entry, and the primary trocar was placed in the left upper quadrant space. Of the 504 potentially risky entries, there were two (0.39%) Veres-needle related and zero trocar-related injuries. All surgical procedures were accomplished laparoscopically, and all entries were accomplished by the left upper quadrant entry technique. Therefore left upper quadrant entry technique is a safe and easily learned alternate access technique.

Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications

OBJECTIVE

To compare the risk of major complications during the set-up procedures for laparoscopy according to whether the classic technique (creation of the pneumoperitoneum followed by introduction of the optics trocar) or open laparoscopy is used.

METHODS

Comparison was made of two retrospective series each carried out in a department promoting one of the two techniques. The setting was a university-affiliated hospital. Two groups of patients were compared: group A, classic laparoscopy, n = 8324; group B, open laparoscopy, n = 1562. We investigated the set-up procedures of operative laparoscopy according to the rules of classic or open laparoscopy.

RESULTS

The risk of failure requiring conversion to laparotomy is significantly higher in the group of patients who underwent open laparoscopy [three cases (0.19%) vs. 0 case (0.0%); p = 0.004]. The risk of major complications is comparable in the two groups [group A, four cases (0.05%) vs. group B, three cases (0.19%); p = 0.08]. In the classic laparoscopy group there were four major complications: one injury to the aorta and three bowel injuries. In the open laparoscopy group there were three major complications: two bowel injuries and one postoperative occlusion.

CONCLUSIONS

Open laparoscopy does not reduce the risk of major complications during the set-up procedures for laparoscopy. Randomized prospective trials are indispensable for comparing the risks involved with the classic technique and those of open laparoscopy.

Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry

OBJECTIVE

To obtain consensus as to the optimal form of entry technique for access to the peritoneal cavity.

DESIGN

A meta-analysis of all relevant English language studies of laparoscopic entry complications.

MAIN OUTCOME MEASURES

Incidence of bowel and major vascular injuries.

RESULTS

Bowel injuries occur in 0.7/1,000 and major vascular injuries in 0.4/1,000. The overall incidence of major injuries at time of entry is 1.1/1,000. The direct entry technique is associated with a significantly reduced major injury incidence of 0.5/1,000, when compared to both open and Veress entry produces (1.1 and 0.9/1,000 respectively, p = 0.0005). Entry-related bowel injuries are reported more often following general surgical laparoscopies than with gynaecological procedures (p = 0.001). No such difference is seen in the incidence of vascular injuries (p = 0.987). Open entry is statistically more likely to be associated with bowel injury than either Veress needle or direct entry However, open entry appears to minimise vascular injury at time of entry.

CONCLUSIONS

There remains no clear evidence as to the optimal form of laparoscopic entry in the low-risk patient. However, direct entry may be an under-utilised and safe alternative to the Veress needle and open entry technique.

Laparoscopic hysterectomy in obese women: a clinical prospective study

OBJECTIVE

To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight.

METHODS

A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a significance level of P=0.05.

RESULTS

Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no significant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the significance of the difference was borderline (P=0.06).

Litigation of laparoscopic major vessel injuries in Canada

This study is a review of conditions and circumstances associated with 15 injuries to great vessels during laparoscopic surgery. Thirteen cases were litigated in Canada and two occurred in the author's operating room. Body habitus may have been an underlying factor in the injuries. Most injuries were entry related and independent on complexity of surgery. One was caused by the Veress needle and one by a secondary trocar, and three occurred during dissection of adhesions. Ten were primary trocar injuries, 9 after pneumoperitoneum and 1 at direct trocar insertion. Of these, five were caused by reusable and five by disposable trocars with so-called safety shields. In 6 of 15 cases recognition of the injury was delayed; 5 in the recovery room. Eleven women had uncomplicated recovery. Of 13 litigated cases, 8 (62%) resulted in settlement.