Laparoscopy and the anterior abdominal wall: a guide to vascular mapping for safe entry
© Springer-Verlag Berlin / Heidelberg 2004
Published: 24 February 2004
Laparoscopy is an invaluable diagnostic and therapeutic tool. Unfortunately, the introduction of trocars into the abdominal cavity is not without certain specific inherent dangers, such as injury to the vasculature of the anterior abdominal wall. This article assesses the normal vasculature of the anterior abdominal wall during laparoscopy as well as various methods, such as pneumoperitoneum pressure and patient positioning, for improving the safety margins for the insertion of umbilical as well lateral trocars.
The development of laproscopic surgery marshalled in a new era in terms of both diagnostics and therapeutics, often eliminating the need for open abdominal surgery. However, as with all developing techniques, as usage increases so does the number of reported associated complications. Although relatively few, minor complications are reported in as many as 5.1% of laparoscopic procedures and major complications in upwards of 2.3% . Complications related to laparoscopic procedures include ureteric injury [2, 3] as well as damage to other internal organs, including the bowels, bladder and uterus . Vascular trauma has also been associated with the placement of needles and trocars, where the incidence of injury to the vessels of the anterior abdominal wall  occurs with greater frequency than injury to deep vessels, such as the aorta and iliac vessels . Despite the use of relatively standardized techniques and increasing experience of the surgeons, complications related to the insertion of trocars still occur .
The anatomical relations of the anterior abdominal wall may be variable and different under pneumoperitoneum. The insufflation of the abdomen will stretch the anterior abdominal wall and change the standard anatomical landmarks and measurements.
The aim of this study was to assess the anatomical relation of the anterior abdominal wall to underlying structures and the effects of manipulation of various parameters during trocar insertion under different pneumoperitoneum pressures.
Materials and methods
Thirty women undergoing diagnostic laparoscopy for the investigation of infertility consented to participate in the study. The study was conducted during the period from March through November 2001. The women were selected based on having no previous history of abdominal surgery. The mean duration of infertility for the group was 6.1 years, the mean age 27.6 years, and the mean body weight 68.3 kg. For the purposes of the study, the patients were divided into three groups. In group A, direct trocar insertion was used in the absence of prior insufflation, while in group B insufflation was used to attain an intraabdominal pressure of between 15 mmHg to 20 mmHg. Finally, group C comprised those patients in whom the intraabdominal pressure was raised to 25 mmHg prior to trocar insertion.
In each patient a preliminary primary puncture was made 5 cm cranial to the symphasis pubis in midline, with a 5 mm trocar through which a 5 mm laproscope was introduced in order to monitor the introduction of the subumbilical 10 mm primary trocar. During the introduction of the main subumbilical 10 mm trocar, the distance between the anterior abdominal wall and the great vessels and viscera was visually observed and assessed. Particular attention was paid to the indentation effects of trocar thrust. In addition trans-illumination techniques were used to assess the location of the inferior epigastric, superficial epigastric and superficial circumflex arteries, as well as the lateral margins of the rectus muscle, in relation to the symphasis pubis, the umbilicus and the abdominal mid-line. The results were evaluated to determine the safest possible entry technique in terms of the following: (1) site of puncture, (2) intra-abdominal pressure adjustment, (3) patient position, (4) trocar type and (5) direction of trocar thrust.
Positions of anterior abdominal vessels from the midline (cm; Fig. 1). The figures in brackets indicate the values obtained in the current study
Distance from symphysis
Inf. epigastric a
Sup. epigastric a
Sup. circumflex a
Lat. margin of rectus m
The umbilicus tends to be used as a landmark from which measurement is made for the positioning of trocars. Furthermore, the position of the umbilicus is used as an indicator of the position of the aortic bifurcation to avoid retroperitoneal vessel injury . The bifurcation is usually located at or cranial to the umbilicus, thus increasing the risk of damage to the vessel during trocar insertion. Pneumoperitoneum always results in the cranial movement of the umbilicus. Where insufflation is used and the pressure created is not sufficiently high, the risk of injury is greater because of the greater force required for insertion and the fact that the indentation of the abdominal wall halves the distance between the skin and the retroperitoneal vessels. Obesity also plays a role in increasing the risk of retroperitoneal vessel injury where it is suggested that trocar insertion occurs at a 90° angle to the skin to avoid preperitoneal placement . Injury to retroperitoneal vessels can, however, be avoided by taking the precautions recommended by Loffer and Pent .
The avoidance of vascular injury during placement of lateral trocars is of paramount importance. The following recommendations are made: (1) In accordance with Hurd et al.  and our observation, in the absence of laparoscopic anatomical landmarks to guide placement, lateral trocars should be inserted at least 5 cm above the pubic symphysis and 8 cm from the linea alba. (2) Umbilical inscision should be strictly intraumbilical and not infraumbilical. The placement of the patient in Trendelenburg’s position should only be carried out after trocar insertion to avoid risk of aorta proximity. (3) The use of insufflation to achieve a pneumoperitoneum with a pressure of 25 mmHg allows for a safer and easier entry technique. (4) Safe trocar entry in the absence of pneumoperitoneum can only be achieved in thin patients with lax abdomens where direct manual abdominal lift can be ensured, preferably using smaller caliber trocars, like the 5 or 7 mm ones. (5) The trocar found to offer the safest use is the short disposable palm trocar, because it requires only half the force for insertion. (6) Finally, an in-depth knowledge of the anatomy of the vasculature of the anterior abdominal wall is one of the cornerstones for safe trocar placement.
The author acknowledges the support of Prof. P. Richards, head of the Department of Anatomy, Medical Faculty, University of Pretoria, South Africa, in fulfilling this research and her continuous collaboration and efforts.
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