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Performing a Safe Laparoscopy |
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THE PNEUMOPERITONEUM
The laparoscopic surgeon should check the position of
the patient prior to initiating the pneumoperitoneum. Positioning the
patient on the operating room table is critical and will significantly
increase intra-abdominal visualization.
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Pneumoperitoneum using a Veress Needle
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We always create the pneumoperitoneum using
a disposable Veress Needle or an Auto Suture SURGINEEDLE*. We have totally
disregarded reusable Veress Needles. Potential catastrophes have occurred
on our surgical service when the spring of the reusable Veress needle
malfunctioned transforming the Veress needle into an uncontrolled
harpooning device. In addition, we continue to question the sterility of
these reusable needles. Veress needles come in two lengths (120 cm and 150
cm); the longer version is obviously for obese patients.
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Pneumoperitoneum using a Veress Needle
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1. Preparation of the Abdomen:
The entire, anterior abdominal wall should be prepped from mid thigh to
the nipple line and as lateral as possible. Laparoscopic procedures can
occasionally become very difficult and may require the insertion of
additional trocars away from the original operating site.
2. Grounding the Patient:
All patients, without exception, should be properly grounded.
3. Insertion of the Veress
Needle: The safest access into the intra-abdominal cavity with a
Veress needle is the sub-umbilical area. The anterior abdominal wall is
the thinnest at this level and all fascial layers are fused into single
fascial planes. Thus, the operator should always attempt to insert the Veress needle at this site in the virgin abdomen.
In morbidly obese patients, use two traumatic
towel clips on each side of the umbilicus to elevate the abdominal wall
prior to attempt to insert the Veress Needle.
| Step 1:
Elevating the Anterior Abdominal Wall |
The anterior abdominal wall needs
to be elevated in order to distance it from the intra-abdominal
contents. This is done by grabbing the abdominal wall directly under
the umbilicus with one hand. If the patient is overweight, two towel
clamps can be used on each side of the umbilicus to achieve the same
result.
A 1 mm incision is made with a # 11 Scalpel below the
umbilicus.
| Step 3:
Inserting the Veress Needle |
The spring function or the
retraction capability of the Veress Needle is checked. The operating
table should be in neutral or flat position. The needle is then slowly
inserted into the incision. It is angled toward the pelvis and
advanced. The operator should feel or sense the needle passing through
two distinct planes.
The needle is advanced and withdrawn
several times. If this is done easily and without obstruction, the tip
is in proper position.
Although we no longer perform
this test routinely, all neophytes laparoscopic surgeon should do so.
Ten cc of normal saline is injected. This should be done easily. The
abdominal pull is then released. The Veress needle is then filled to
the rim with normal saline (or a open syringe can be used). The
tension on the skin is resumed and the level of saline should
immediately drop if the needle is in proper intra-abdominal position.
| Step 5:
Initiating the Insufflation |
The Veress needle is then
connected to the CO2 insufflation tubing (a filter should be used).
Insufflation is initiated at a low flow. Intra-abdominal pressure
recorded at this point should not exceed 8 mm Hg. Entry pressure at
low flow should be checked immediately while the abdominal wall is
still elevated. If higher, move the needle around or resume the pull
on the skin or anterior abdominal wall. If the pressure is too high,
the Veress needle it is not in the right position and needs to be
removed. Begin again.
If in place, switch to high flow and
inflate the intra-abdominal cavity.
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Pneumoperitoneum using the VERSASTEP
SYSTEM™ |
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USSC VERSASTEP™
The
Versa-Step System is an integrated system combining a Nylon
stretchable sheath over a Disposable Veress needle. Once inserted,
the sheath is dilated by inserting the trocar [with a dilator in
place]. The real advantage of this system is that it has no cutting
entry blade, thus dramatically decreasing trocar site bleed and the
potential for an intra-abdominal injury. In addition, it creates a smaller
fascial defect which
does not need to be closed [up to 12mm]. |
| Insertion
of the VersaStep™ System Trocar |
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Following insufflation
the expandable needle system is inserted, the needle is withdrawn
leaving the expandable sleeve in place.
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A tapered blunt dilator
is inserted through the sleeve, dilating the tract created by the
needle.
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The trocar is maintained in place by the expandable
sleeve.
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Pneumoperitoneum with a Blunt Trocar |
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The blunt trocar is
used to safely create a Pneumoperitoneum in the scarred abdomen. It
is inserted by making an initial skin and a fascial incision. The
fascial incision should be 1 to 1.5 cm in size. A long suture (2.0)
is placed on each fascial edges. With finger dissection a tunnel or
an opening into the intraabdominal cavity is gently created. The
BluntPort* is then inserted. The foamgrip anchoring device is set
and secured with the previously placed suture. The insufflation port
is connected to the insufflation tubing and the pneumoperitoneum
created. |
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Using a VISIPORT™ or Direct
Visualization |
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IA 1 cm skin
incision is made with a plain scalpel. A telescope is inserted into
the VISIPORT OPTICAL TROCAR* and the path of entry of the VISIPORT
OPTICAL TROCAR* into intra-abdominal cavity is visualized. The
VISISPORT OPTICAL TROCAR* is advanced slowly through the different
planes of the abdominal wall. These planes are cut slowly with the
blade of the VISIPORT OPTICAL TROCAR* (at the tip of the instrument)
until the intraabdominal cavity is reached. Pneumoperitoneum must be
created or abdominal wall elevation must be performed prior to the
insertion of the VISIPORT* OPTICAL TROCAR. |
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Using a Storz Termanian™ Trocar
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The Termanian® Type trocar has greatly
improved the safety and function of the re-usable trocar. This is the only
re-usable trocar we use. It is inserted via a small incision without
a pneumoperitoneum and rotating while advancing it. All the
abdominal wall layers are well seen and visualized.
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Maintaining the Pneumoperitoneum |
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A laparoscopy can be performed without
significant, deleterious effect with intraabdominal pressures up to 20 mm
Hg. However, some laparoscopic inguinal hernia repairs require higher
pressures in the 18 and 20 mm Hg. range to achieve necessary additional
exposure.
Our guidelines are simple.
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intra-abdominal pressures are between 10 to 15 mm Hg. The
visualization of this type of intra-abdominal pressure can be further
enhanced by modifying the patients’ position (operating table position
to Trendelenburg to reverse, etc.) |
| Higher pressures in the 15 to 20
mm Hg range are suboptimal. There is a definite correlation
with increased postoperative patient discomfort and recovery and the use
of increased intra-abdominal pressure. |
| Pressures beyond 20 mm Hg
are classified as dangerous with potential hemodynamic and pulmonary
compromise and long term effects on the intra-abdominal wall musculature.
When such pressures are used, some patients will actually
report increased abdominal girth and a bloating post-operative feeling
which persisted for months after the procedure in spite of intensive
exercise. |
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