Methods to Prevent Laparoscopy Complications

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Dr. Bernd Bojahr: "Hello, my name is Dr. Bojahr; I come from Germany, and I'm here in Chicago at the ISGE meeting. I have my friend, Professor Peter Maher, from Mercy Hospital in Melbourne with me and we want to speak about laparoscopy. He is a very experienced laparoscopist from Australia and he has a lot of experience with complications. I have some questions for you - you are a very experienced laparoscopist so what kind of methods do you use to prevent complications in operative laparoscopy?"

Professor Peter Maher: "Thanks very much, Bernd. It's great to see you again in Chicago and I look forward to seeing you next year in Berlin. Laparoscopy, as you know, has really been present over the last eleven years in the form that we know it now - i.e. complicated operative laparoscopic procedures that can be done. Unfortunately, around the world the down side of laparoscopic surgery has been the apparently higher incidence of complications and I think we've all tried to look at ways of minimizing the complications. In my experience, I think that the minimization probably starts in the office when you first see the patient. If you're very, very busy and the patients are being put through at a reasonable rate, you often don't take into account situations that may increase your complication rate, things such as a previous laparotomy, hernia repair, or caesarian section. I think particularly important is the body habitus of the patient that may influence your trocar positioning, your primary trocar insertion, and even whether or not you use a Veress needle or an open Hasson technique."

Dr. Bernd Bojahr: "I agree with you but I have a question - does this mean in these cases you don't perform laparoscopy if they've had a previous surgery or do you perform a special technique, for example, to introduce an instrument or what do you mean with the indications?"

Professor Peter Maher: "Yes, in my own practice I'm not generally recommending but I actually use a direct trocar technique but that is only on patients who have not had previous surgery of any kind intra-abdominally. If patients have in fact had previous surgery, I tend to use a Veress needle. I think that if one does use a Veress needle you should always use a disposable Veress needle. I think that we've seen over the last twelve years or so a huge increase and a decrease in the use of disposable instruments but the only one that should remain disposable is probably the Veress needle because of its sharpness and because insertion is totally dependent on feel. So I would use my normal technique in a virgin of diamond but I would with a low transverse incision, for example, put the Veress needle in the base of the umbilicus and then use a water test with an open syringe, pour water in it, and if it flowed in easily I'd feel confident that it was probably in the right place. But for patients who have midline incisions, for example, I would use palm-ers point or the ninth intercostal space. I think that laparoscopic surgery is appropriate in properly selected cases. I think we can minimize complications by careful patient selection, by careful operation selection, and in particular, I think it's most appropriate that the surgeon performing the operation is very, very familiar with the appropriate techniques. I think we'd all agree as laparoscopists that it's something that must be learned, it's not something inherent of being a gynecologist so that's the way that we'll come the full circle and have a good outcome with minimum of complications."

Dr. Bernd Bojahr: "Thank you, Peter. I hope to meet you next year in Berlin at the ISGE meeting."

Professor Peter Maher: "I look forward to it, Bernd, thanks very much."