Laparoscopy and entry

RCOG Basic Practical Skills

Laparoscopic entry techniques

What to expect:
1. Position of patient
2. Primary port closed entry
3. Secondary port entry
4. Primary port alternatives
5. Exit techniques
6. Reference to RCOG Green Top
Guideline 49 - PREVENTING ENTRYRELATED GYNAECOLOGICAL
LAPAROSCOPIC INJURIES
Royal College of Obstetricians and Gynaecologists

1. Position

Prone
Stirrups/Lloyd Davis
Non slip mattress
Trendelenberg after ports

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

The operating table should be
horizontal (not in the Trendelenberg
tilt) at the start of the procedure
The abdomen should be palpated to
check for any masses before insertion
of the Veress needle

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2. Primary port
closed
entry
Why intra umbilical entry?

Fixed peritoneum
Thin
Least vascular
Cosmetic

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

The primary incision for laparoscopy
should be vertical from the base of the
umbilicus (not in the skin below the
umbilicus)
Care should be taken not to incise so
deeply as to enter the peritoneal cavity.

Royal College of Obstetricians and Gynaecologists

2. Primary port
closed
entry
Insertion of Veress needle
Pencil grip
Vertical, then towards pelvis
Double click

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
The Veress needle should be sharp, with
a good and tested spring action. A
disposable needle is recommended
The lower abdominal wall should be
stabilised in such a way that the Veress
needle can be inserted at right angles to
the skin
Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
Two audible clicks are usually heard as the
layers of the umbilicus are penetrated.
Excessive lateral movement of the needle
should be avoided. This may convert a small
needle point injury in the wall of the bowel or
vessel into a complex tear

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2. Primary port closed entry

Saline test
Withdraw
Instil
Withdraw

If no fluid, frank blood (or faeces) then

proceed with insufflation
Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

The saline test not 100% accurate

The most valuable test of correct placement
of the Veress needle is to observe that the
initial insufflation pressure is relatively low
(less than 8mmHg) and is flowing freely
After 2 failed attempts to insert the Veress
needle, either the open Hasson technique
or Palmers point entry should be used.
Royal College of Obstetricians and Gynaecologists

2. Primary port closed entry

Insufflation
Set pressure cut of to at least 20-25mmHg
Start at low flow (1L/min)
Check gas entering at low pressure
(<8mmHg)
After 0.5L flow rate can be increased
Insufflate to pressure cut of (20-25mmHg)

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2. Primary port closed entry

The greater the gas bubble &
abdominal wall tension the less the
risk of bowel injury
Abdominal pressure= 8mmHg

Abdominal pressure=25mmHg

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Green-top Guideline. No. 49 May

2008

An intra-abdominal pressure of 2025

mmHg should be achieved before
inserting the primary trocar
The distension pressure should be
reduced to 1215 mmHg once the
insertion of the trocars is complete

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
The primary trocar should be inserted at 90
degrees to the skin, through the incision at
the base of the umbilicus
Once the laparoscope has been introduced it
should be rotated through 360 degrees to
check for any adherent bowel

Royal College of Obstetricians and Gynaecologists

2. Primary port
closed
entry
Commonest problem - failed entry

Insertion of subumbilical Veress needle

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2. Primary port closed entry

Closed entry can still cause bowel
injury, especially if adhesions are
present

Royal College of Obstetricians and Gynaecologists

2. Primary port
closed entry

Other injuries
Vascular injury
Retroperitoneal
haemorrhage
Bladder injury
Injury to over inflated
stomach

Royal College of Obstetricians and Gynaecologists

3. Secondary ports
Secondary ports are inserted under
direct vision - an inadvertent injury from
a secondary port could be considered
negligent
Principles
Avoid inferior epigastric vessels
Avoid bowel/vascular injury
Minimise hernia risk

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
Secondary ports inserted under direct
vision at right angles to the skin at 2025
mmHg pneumoperitoneum
Inferior epigastric vessels should be
visualised laparoscopically prior to
secondary port placement
Once the trocar has pierced the
peritoneum it should be angled towards
the anterior pelvis
Royal College of Obstetricians and Gynaecologists

3. Secondary ports Anatomy

Mid-line
Rectus muscles
Obliterated umbilical artery

Round ligament

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3. Secondary ports Anatomy

Inf epigastric artery

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4. Primary port
Alternatives

Alternatives to closed umbilical entry

considered:
If there is risk of umbilical adhesions previous (midline) laparotomy
In very slim or morbidly obese women
Failed saline test or Veress insertion x2
Unsatisfactory closed Veress insufflation

Alternatives include:
Open entry variations of Hassan technique
Palmers point closed entry
Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
When Hasson open laparoscopic entry is
employed, confirm that the peritoneum has
been opened by visualising bowel or
omentum
Palmers point is the preferred alternative
trocar insertion site, except in cases of
previous surgery in this area or
splenomegaly.
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5. Exit techniques
Under direct view to identify:
Bleeding
Injury to omentum
Injury to bowel
- (partial/complete)

Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May

2008
On removal of a laparoscope. Check by
direct visualisation that there has not
been a through-and-through injury of
bowel adherent under the umbilicus
Secondary ports must be removed under
direct vision to ensure that any
haemorrhage can be observed and
treated, if present.
Royal College of Obstetricians and Gynaecologists

5. Exit techniques
Wound closure:
Proper closure of fascia within
umbilical port site to prevent wound
dehiscence or hernia
Avoid hernia risk by closing sheath:
- Midline port sites > 7mm
- Lateral port sites > 5 mm

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Now show the Video: Closed

laparoscopic entry technique

Now show the video: Alternative

laparoscopic entry techniques

Royal College of Obstetricians and Gynaecologists