Abdominal entry in laparoscopic surgery

In the U.S., millions of laparoscopic surgeries are performed each year.¹ While the benefits of laparoscopic surgery compared with abdominal procedures are well established, it poses one unique life-threatening risk: laparoscopic abdominal entry.²

Though often the shortest part of any laparoscopic procedure, laparoscopic abdominal entry accounts for approximately 50% of serious laparoscopic complications and medico-legal litigations related to laparoscopy.^2,3

Life-threatening complications of laparoscopic entry are rare – estimated to be 0.4 cases per 1000 cases for gastrointestinal injury and 0.2 cases per 1000 cases for major vascular injury.² However, when considering nearly 5 million laparoscopic procedures are performed in the United States each year, it is likely at least one patient per day has a serious complication or dies as a result of abdominal entry each day.⁴

Injuries related to abdominal entry

Regardless of technique, the risks associated with laparoscopic entry include perforation of the bowel or bladder, vascular injury, solid organ injury, nerve injury, port site hernia and surgical site infection.⁵ Injury can occur as a result of Veres entry, primary port entry or secondary port entry. However, just those risks, specific to initial laparoscopic entry, will be discussed in this review. Major complications have been reported with every type of laparoscopic entry.²

Vascular Injury

Rates of venous or arterial injury at the time of laparoscopic entry are rare, 0.1 to 6.4 injuries per 1000 cases.⁶ The consequences of vascular injury can be rapidly devastating, and it is estimated that 15% of such injuries are fatal.⁷

Other sources report that 81% of trocar-related deaths are as a result of vascular injury.8 In an analysis of trocar-associated injuries reported to the Food and Drug Administration (FDA) between 1997 and 2002, vascular injuries accounted for 25 of 31 fatal injuries.⁵ This included 11 injuries to the aorta, 3 to the vena cava, 5 to an iliac artery or vein, 1 to a gastric vessel, 1 to a hepatic vessel and 4 to an unspecified site.⁵

An additional 261 non-fatal vascular injuries were also reported. Unfortunately, device injuries tend to be underreported and this study likely only represents a small portion of patients with a trocar-related vascular injury.

Immediate recognition of retroperitoneal major vascular injury (aorta, vena cava, iliac vessels) is essential to prevent exsanguination. If not promptly recognized, intravascular insufflation with pneumoperitoneum can cause an air embolism resulting in ischemia, cardiac arrythmia and death.⁹

Appreciation of a major vascular injury can be delayed if bleeding collects in the retroperitoneum and hemodynamic instability may be the first sign.¹⁰ When recognized, such a major vascular injury is managed with immediate pressure, laparotomy, emergent vascular surgery consultation, and coordination with the anesthetic team for prompt transfusion.

More minor vascular injuries also can have serious implications and may be more difficult to diagnose. Such vessels include those of the anterior abdominal wall, omentum, and organ-specific vessels. Mesenteric and omental injuries are most commonly injured vessels on initial entry^11,12, but the inferior epigastric vessels are the most common overall vascular injury at the time of laparoscopy.¹³ Injury to the inferior epigastric vessels in the lower quadrants should be avoided by placing secondary trocars under direct vision.¹⁰

Gastrointestinal Injury

The second leading cause of major injury and death from laparoscopic entry is damage to the gastrointestinal tract.⁷ While the impacts of bowel injury at the time of laparoscopy are not immediately life threatening like a vascular injury, they are deadly in that they are not easily recognized. Delayed diagnosis of bowel injury is a significant cause of post-operative mortality after laparoscopic surgery.^{6, 14}

In the previously mentioned report of trocar-related injuries reported to the FDA, 6 of the 31 fatal injuries involved a bowel injury.⁵ Of these deaths, 5 occurred outside of the immediate post-operative period, ranging from post-operative day 4 to 21.⁵ An additional 69 non-fatal hollow viscus injuries were also reported, but again, under-reporting is suspected.

In a large retrospective study of gynecologic surgeries in which bowel injury occurred, 33% of injuries occurred with the use of the Veres needle, 50% with placement of an umbilical trocar and 17% with placement of an additional trocar.¹⁵

In a study from the Journal of Urology, nearly half of bowel injuries were not recognized at the time of surgery.¹⁴

If discovered intraoperatively, bowel repair can be accomplished non-urgently by primary repair in two layers or via bowel resection depending on the size of the injury.¹⁶ Consultation with a bowel surgeon is recommended. Very small injuries, such as those caused by the Veres needle, may be managed expectantly.¹⁷

A high index of suspicion and making a timely diagnosis are the keys to prevention of death and serious complication from intestinal injury. Reported clues that a bowel injury may have occurred include difficultly maintaining peritoneum, direct visualization of bowel contents and bubbling in irrigation fluid, but these signs are unlikely to be present with a small injury.^10,17

Post-operatively a bowel injury should be considered in patients who present with fever, tachycardia, tachypnea, worsening abdominal pain, bloating, nausea/vomiting, poor oral intake or ileus.¹⁸ Bowel injury can be detected on a CT scan with oral contrast.¹⁷ Treatment includes intravenous antibiotics and surgical exploration with closure or resection of the injured area.

Comparison of entry techniques

There are many ways to safely obtain abdominal access in laparoscopy (Table 1). There have been theories proposed regarding why some sites and entry techniques may be safer than others. However, given the rarity of catastrophic events at the time of laparoscopic entry, trials are exceedingly difficult to design with adequate power to see a difference between techniques. Meta-analysis has been used as a tool to combat the low event rate, but likely still fails to capture accurate data on such rare events.

One such meta-analysis is the 2019 update of the Cochrane Review on laparoscopic entry technique. This review included 57 randomized trials with 9,865 participants.¹⁸ However, the results are severely limited by low event rates and high risk of bias in most studies.

Evidence on the subject is insufficient to show differences in major injury (vascular, visceral, or other) between open and closed techniques, Veres entry and direct entry or Veres and direct vision entry. This study, as with others before it, leaves surgeons with little evidence-based guidance on choosing one entry technique over another (Table 2).

Though very few differences were discernable for entry techniques there were some differences in occurrences of minor complications.

An open technique was favored over closed techniques in terms of omental injury and extraperitoneal insufflation. However, when lower quality studies were removed, the open technique’s advantage for extraperitoneal insufflation was no longer significant. In addition, direct entry was favored over Veres entry in terms of failed entry, omental injury, and extraperitoneal insufflation.¹⁸

With such a paucity of data to guide which entry technique is best to use, we recommend routine utilization of multiple entry techniques and entry sites. This will allow the surgeon to be comfortable troubleshooting difficult entries and patients with complex surgical histories.

Recommendations for safe entry

Below, we review recommendations for safe abdominal entry at various sites of entry and for various entry techniques. Some are evidence-based, and others based on expert opinion.

General Recommendations

• Place a urinary catheter and gastric tube (for upper abdominal entry) to decrease risk of iatrogenic injuries to the bladder and stomach.¹⁹ Injury still is possible.
• Avoid long and sharply pointed blades for skin incisions, which could penetrate the anterior abdominal wall and cause injury in thin women.^19,20
• Place primary entry device while patient is horizontal to maintain your orientation of underlaying structures.²
• Consider elevation of the abdominal wall to increase distance to underlying structures.2,19,21 Understand this has not been shown to reduce visceral or vascular injuries, and the practice may also increase failed entry attempts.¹⁸
• Enter away from site of suspected adhesions.¹⁶
• Use high pressure (20-25 mmHg) when placing trocars to maximize distance to underlaying structures, then reduce pressure to 15 or lower after trocars are placed.²

Site-specific recommendations

Umbilical entry:

• Make your skin incision truly in the base of the umbilicus, where the abdominal wall is thinnest.²
• If using the Veres, feel for “two pops:” one as the fascia is pierced and the other for the peritoneum.¹⁰
• Caudal displacement of umbilicus to minimize risk to great vessels.²²
• Angulation of Veres needle to 45 degrees in thin women to avoid the great vessels in close proximity to anterior abdominal wall.19 Understand this will increase proximity to the left common iliac vein.¹⁰
• Palmer’s Point: (Mid-clavicular line 3 to 4 cm below the costal margin).
• Advantageous for patients with prior midline vertical incision, umbilical hernia, gravid uterus and enlarged uteri.¹⁰
• May have an advantage over the umbilicus in obese patients with a large pannus.¹⁰
• If using Veres, feel for “3 pops:” one for the aponeuroses of the internal/external oblique, one for the aponeuroses of the internal oblique/transverus abdominus and one for the peritoneum.¹⁰
• Avoid for splenomegaly, hepatomegaly, portal HTN, gastric/pancreatic masses, or suspected upper abdominal adhesions.²

Alternative sites to consider:

• Lee-Huang Point (midpoint between umbilicus and xiphoid): similar advantages to Palmer’s Point, but with midline anatomy, which may ease entry in obese patients. Midline location may be preferable if the port will be used for the camera.²
• Jain Point (2.5 cm left lateral to umbilicus): avoids umbilicus and left upper quadrant, but risks injury to epigastric vessels, which are not easily visualized there.²³
• Posterior Vaginal Fornix or Uterine Fundus: Can be considered in patients with significant abdominal adhesions and no history of endometriosis, pelvic inflammatory disease or pelvic surgery.¹⁰

Special considerations for Veres entry

• Test to confirm placement of the Veres needle (i.e. saline drop test, intra-abdominal pressure reading), understanding none of these tests is perfect.²⁴
• Initial intra-abdominal pressure reading should be under 8 mmHg on entry.²⁵
• Rate of Veres-related injury increases with each attempt. After 2 to 3 failed attempts a different site or technique should be tried.²⁵

^{Special considerations for open entry:}

• Avoid in very obese patients in which the fascia will be hard to locate. However, it can be considered if the abdominal wall is too thick to accommodate Veress or direct entry.²⁶
• Avoid creating an incision too large for the trocar, leading to leak of peritoneum.²⁶
• Consider this technique for pelvic pathology at risk of penetration by the Veress needle.¹⁰
• May increase operative time, if not well practiced by surgical team.²⁷
• Generally requires use of a 10 to 12 mm trocar.

Special considerations for direct entry:

• Advantage of fastest method of entry.²⁰
• Use the laparoscope for vision to aid in detection of injury.

Conclusion

Laparoscopic abdominal entry is the most dangerous part of any laparoscopic procedure, though major complications are rare. No one entry technique or location has been convincingly proven to be superior to any other with regard to prevention of major complication.

Surgeons should be comfortable with a range of entry techniques and locations to allow safe entry in patients with various body habitus and surgical histories.

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References

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