Concerns With Entry Techniques

Audio/Video Link  *requires RealPlayer - free download

Dr. James Carter:  “We’re here at the ISGE meeting in Cairo, and we’re speaking with Dr. Duncan Turner about concerns with entry techniques.”

Dr. Duncan Turner:  “A lot of laparoscopies have been done these days and for good reason, the patients benefit tremendously from them but they’re not without some danger.  As opposed to most operations, the main danger is at entry, right at the beginning of the operation rather than and perhaps technically the most difficult part.  I think there is some very simple techniques that can be utilized to decrease the risk to patients and avoid some of the tragedies that have occurred with laparoscopic surgery or, in fact, with any surgery on entry techniques.  Certainly there is a controversy as to whether in points of view an open or closed technique, and my personal choice is to use a closed technique which means making an incision in the naval and putting a Veress needle through it and inflating the abdomen in that manner.  There have been various pieces of equipment that have been developed to try and cut down the risk of these techniques.  But probably a few basic rules need to be undertaken to avoid most of the problems.  First of all, a disposable Veress needle probably should be used because you need one that functions perfectly and is sharp every time.  Secondly, there’s a particular direction - the incision needs to be made right into the bottom so to speak of the naval rather than the lower or inferior margin.  It should be deep in the navel because this is where the abdomen is at its thinnest point.  If it is made then towards the pelvis, by putting the needle in that direction one should be able to avoid the major vessels in the abdomen.  Then doing some very simple tests to see that intra-abdominal placement is correct - withdrawal technique or hanging drop technique that are both familiar to most laparoscopists.  Once we’ve obtained the intra-abdominal entry, we insufflate the abdomen with carbon dioxide, and the second trick that I think is important is to inflate the abdomen initially to 20-25 mm of pressure.  A lot of gynecologists will look at the volume that goes into the abdominal cavity and believe then that they have the right amount of cushion but the fact is the pressure is much more important.  Initially the pressure should be 4 mm to perhaps 8 mm as the flow goes in but then reaching a pressure of 20-25 so we have very good distension.  Following this, the primary trocar can be placed and perhaps an ideal technique is the use of mini-endoscopy 2 cm or 3 cm laparoscopes utilized at this time so that we can really confirm visually intra-abdominal placement with very little risk damage before placing a larger trocar.  The so-called safety shield of trocars are not safely shielded, and the FDA have determined that it’s not appropriate to call them safety shields.  But the techniques just to apply as little pressure as possible, perhaps using the radially expanding system or Storz’s Endotip device could be utilized also at this time.  If you use those techniques, I think the risk of damage is very, very small.  The second problem that we face is in the high-risk patient.  Any patient who’s had previous surgery is essentially at high risk for inter-abdominal adhesions and what we call type II injuries where the bowel is adhered to the abdominal wall.  I would strongly suggest the left upper quadrant of entry in a similar manner of distension of the abdomen with a Veress needle as I suggested earlier.  I think if you utilize these, the chances of encountering any problems with laparoscopic surgery are greatly diminished and we can continue to give the best to our patients.”

Dr. James Carter:  “So Duncan, three major points, one - use a sharp disposable Veress needle.  Two - use a 2 mm or 3 mm laparoscope in high-risk situations to check placement.  Three - use either a radially expanding Step system such as made by InnerDyne or the Storz system or use a 25 mm pressure system if a direct puncture is made.  And four - I guess there’s a fourth point, use the left upper quadrant if you’re suspicious of adhesions.  Is that the fourth point?”

Dr. Duncan Turner:  “Yes, that is the fourth point.  It’s been shown very clearly that the risk of adhesions in the left upper quadrant, providing there hasn’t been surgery in that area, is extremely low and a very safe way to do this.”

Dr. James Carter:  “Thank you, Duncan, and thanks for coming to Cairo to be with the ISGE meeting.”

Dr. Duncan Turner:  “My pleasure, thank you.”