- Review article
- Open Access
Laparoscopic entry techniques: a protocol for daily gynaecological practice in The Netherlands
© Springer-Verlag Berlin / Heidelberg 2006
- Received: 1 September 2005
- Accepted: 23 December 2005
- Published: 3 March 2006
This Dutch model protocol aims to formulate recommendations on insertion of laparoscopic instruments in order to reduce entry-related complications. It was written on behalf of the Dutch Society of Gynaecological Endoscopy and Minimal Invasive Surgery and serves as guidance to safe entry in laparoscopy for the Dutch gynaecologist in daily practice. It was translated and made suitable for publication in English. Despite the variety of methods described for creating pneumoperitoneum, no one single method can claim to be fundamentally superior to another. The practising laparoscopist should be familiar with at least more than one entry technique.
- Entry techniques
The creation of the pneumoperitoneum remains the first step of a laparoscopic procedure. The complication rate of laparoscopy is 5.7/1,000 procedures . It has been calculated that one half of all laparoscopic complications are entry related [1–3]. Entry-related complications are either due to introduction of the Veress needle or to primary or secondary trocars. In a Dutch survey, 0.3/1,000 injuries were caused by the Veress needle, 1.9/1,000 by the primary trocar, and 0.8/1,000 by a secondary trocar . Entry-related complications can be divided into two categories: vascular injuries and visceral injuries. Vascular injuries comprise injuries to the superficial vessels of the abdominal wall (such as epigastric vessels) and to the large blood vessels deeper in the abdomen. Visceral injuries comprise injuries of the bowel, stomach, and omentum and in the pelvis, the uterus and the bladder. These can occur both in cases of normal abdominal anatomy and in anatomical variations caused by pathology such as adhesions or enlarged structures. Risk factors for entry-related complications can be identified, which include adhesions due to previous abdominal surgery, especially median laparotomy; peritoneal infections; and large intraabdominal tumours. Clinical research has not confirmed the often-mentioned risk factor of high body mass index (BMI).
No publications on the subject were found in the Cochrane Library, nor were controlled trials found in the Cochrane Register. A PubMed search was performed with relevant MeSH terms (1996–2002), and cross references were sought in Medline journals and journals that are not part of the Medline database. The subject was further discussed at meetings of the Dutch Society of Gynaecological Endoscopy and Minimal Invasive Surgery on three different occasions. This review was updated with Jansen et al.'s 2004 publication .
It is advisable to have laparotomy instruments at hand in case of serious entry-related injuries. The first step is to visualise the intraabdominal space. Recognising the patient’s physical appearance and abdominal wall morphology and palpating the bifurcation of the aorta and promontory and iliac crests may help in visualising the intraabdominal space. The bifurcation of the aorta is positioned between the 4th and 5th lumbar vertebrae. The umbilical region is situated opposite the 3rd and 4th lumbar vertebrae. The angle between the large blood vessels and the horizontal plane may vary according to the patient's position. Insertion of the Veress needle in a patient in Trendelenburg position is not recommended, or the angle of insertion should be adjusted because the bifurcation of the aorta may be more cranial than when the patient is in a horizontal position. Furthermore, the position of the umbilicus in relation to the large blood vessels correlates with the patient’s abdominal mass and body weight. With respect to the bladder, catheterisation of the bladder has been proposed to decrease bladder lesions. In contrast, others have proposed filling the bladder to visualise its cranial borders and thereby prevent bladder injuries.
Introduction of the Veress needle
The closed laparoscopic entry technique with the use of a Veress needle for insufflation followed by the blind insertion of a sharp trocar remains the most common approach used by gynaecologists . The Veress needle consists of a blunt-tipped, spring-loaded inner stylet and a sharp outer needle that penetrates the tissue layers of the abdominal wall. Before introduction of the Veress needle, the needle is checked by retracting the stylet by its spring and then passing gas through the needle to confirm its patency. After a small abdominal incision in the (sub)umbilical region, the Veress needle is introduced in the abdomen by lifting the abdominal wall, preferably by hand. The Veress needle is introduced in a right angle to the horizontal plane of the patient on the operating table. The hand that guides the Veress needle rests on the abdomen to ensure controlled entry of the needle into it. During introduction of the needle, two “clicks” can be heard or felt, one when penetrating the fascia of the rectal abdominal muscle and another when penetrating the parietal peritoneum. After having passed the fascia, further introduction of the needle can progress at a 45º angle to the operating table. Once the peritoneal cavity is entered, tissue resistance dissipates, and the stylet springs back into position, thus presenting a blunt-tipped surface to the structures inside the peritoneal cavity. After insertion into the abdominal space, the needle's position can be tested by an aspiration test; aspiration with an empty syringe attached to the needle can confirm the presence of the needle in the abdominal space and not inside a blood vessel or the bowel . Other tests rely on the principle of negative intraperitoneal pressure, such as hanging a drop of saline on the tip of the Veress needle; it is then sucked into the abdomen through the open Veress needle upon rapid elevation of the abdominal wall.
Laparoscopic entry techniques (+ recommended, ± can be considered, – not advisable)
Previous lower abdominal median laparotomy
Veress 12 mmHg
Veress 20–24 mmHg
Placement of primary trocar
After satisfactory insufflation, the next step requires blind insertion of a large-diameter trocar for the laparoscope itself, usually in the same entry port as the Veress needle. With the insertion of the primary trocar, one should again keep in mind the position of the patient and of the large blood vessels, in the same way as with insertion of the Veress needle. In the case of low distension pressure, the trocar is introduced in the exact same way as the Veress needle. In the case of hyperdistension (24 mmHg), the abdominal wall need not be lifted, and the trocar is introduced in a right angle to the abdominal wall.
An alternative method for introducing the trocar is direct trocar insertion (Table 1). This procedure involves an infraumbilical skin incision, grasping and elevation of the abdominal wall, and insertion of the trocar directed toward the uterine fundus. This technique theoretically has the advantage of only one “blind” insertion (instead of two, with a trocar following insertion of a Veress needle). On the other hand, damage in the case of vessel or bowel lesion is more pronounced. Clinical research is contradictory . After insertion of the primary trocar, the laparoscope is introduced and the abdominal cavity inspected 360°. After inspection, the patient is placed in Trendelenburg position.
Placement of secondary trocars
Insertion of the secondary (and third, etc.) trocar should be done under direct laparoscopic control. The insertion place is chosen with the aid of transillumination through the abdominal wall, thereby identifying the superficial epigastric vessels. The inferior epigastric vessels can be visualised directly from inside the abdominal cavity. They run vertically in the anterior abdominal wall 5.5 cm lateral to the midline . Lesions to the epigastric vessels caused by secondary trocars are the most frequent of all vascular lesions related to insertion (0.2–6/1,000) [9, 10].
Removal of trocars
It is advisable to remove the primary and secondary trocars under direct visualisation—for the primary trocar, with the laparoscope inside the trocar. A bowel perforation or a bowel herniation can thereby be seen.
Despite the variety of methods described for creating pneumoperitoneum, no one single method can claim to be fundamentally superior to another. The practising laparoscopist should be familiar with more than one entry technique, preferably two more. In the absence of randomised controlled trials, the safest technique remains that which is most familiar to the individual surgeon. In gynaecological laparoscopy, the closed-entry technique remains the technique most commonly used and the one with the lowest complication rate. For all patients, it might be recommended to create hyperdistension up to 20–24 mmHg to prevent lesions of structures in the posterior abdominal cavity. The optical trocar can be introduced under visual guidance of a needle scope. The use of open techniques may be considered as well if sufficient experience is available. The selection of patients for an open- or alternative-entry procedure can still be recommended.
- Jansen FW, Kapiteyn K, Trimbos-Kemper GCM, Hermans J, Trimbos JB (1997) Complications of laparoscopy: a prospective multicenter observational study. BJOG 104:595–600View ArticleGoogle Scholar
- Härkki-Sirén P, Kurki T (1997) Nationwide analysis of laparoscopic complications. Obstet Gynecol 89:108–112View ArticlePubMedGoogle Scholar
- Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A et al (2002) The European Association for Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 16:1121–1143View ArticlePubMedGoogle Scholar
- Jansen FW, Kolkman W, Bakkum EA, De Kroon CD, Trimbos-Kemper GCM, Trimbos JB (2004) Complications of laparoscopy: an inquiry about closed- versus open-entry technique. Am J Obstet Gynecol 190:634–638View ArticlePubMedGoogle Scholar
- [No authors listed] (1999) A consensus document concerning laparoscopic entry techniques: Middlesbrough, March 19–20 1999. Gynaecol Endosc 8:403–406Google Scholar
- Philips G, Garry R, Kumar C, Reich H (1999) How much gas is required for initial insufflation at laparoscopy? Gynaecol Endosc 8:369–374View ArticleGoogle Scholar
- Rosen DMB, Chapman AM, Carlton M, Cario GM (1998) Methods of creating pneumoperitoneum: a review of techniques and complications. Obstet Gynecol Surv 53:167–174View ArticlePubMedGoogle Scholar
- Hurd WW, Bude RO, DeLancey JO, Newman JS (1994) The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 171:642–646PubMedGoogle Scholar
- Reich H, Rasmussen C, Vidali A (1998) Peritoneal hyperdistension for trocar insertion. Modifications of the closed technique. Gynaecol Endosc 375–77Google Scholar
- Vilos GA (2000) Litigation of laparoscopic major vessel injuries in Canada. J Am Assoc Gynecol Laparosc 7:503–509PubMedView ArticleGoogle Scholar
- Brill AI (2002) Laparoscopic peritoneal access. Laparoscopic access and instrument ergonomics. A primer in gynecologic endoscopy. American Association of Gynecologic LaparoscopistsGoogle Scholar
- Bonjer HJ, Hazebroek EJ, Kazemier G, Giuffrida MC, Meijer WS, Lange JF (1997) Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 84:599–602PubMedView ArticleGoogle Scholar
- Hasson HM (1971) A modified instrument and method for laparoscopy. Am J Obstet Gynecol 110:886–887PubMedGoogle Scholar
- Levy BS, Hullka JF, Peterson HB, Philips JM (1994) Operative laparoscopy: American Association of Gynecologic Laparoscopists 1993 membership survey. J Am Assoc Gynecol Laparosc 1:301–305PubMedView ArticleGoogle Scholar
- Garry R (1997) Complications of laparoscopic entry. Gynecol Endosc 6:319–329View ArticleGoogle Scholar
- Audebert AJM (1999) The role of microlaparoscopy for safer wall entry: incidence of umbilical adhesion according to past surgical history. Modifications of the closed technique. Gynaecol Endosc 8:363–367View ArticleGoogle Scholar
- Bateman BG, Kolp LA, Hoeger K (1996) Complications of laparoscopy—operative and diagnostic. Fertil Steril 66:30–35PubMedGoogle Scholar