Hasson's cut-down technique through Palmer's point

Background

Response Letter to Article:

Direct optical entry through Palmer's point:

A new technique for those at risk of entry-related trauma at laparoscopy

Aust TR, Kayani SI, Rowlands DJ

Gynecol Surg 2010; 7:315–317

We read with interest the recent report of an alternative laparoscopic entry method proposed by Aust et al. for those gynaecological patients who are at risk of bowel injury as a result of periumbilical adhesions, as well as very thin or morbidly obese patients who require an alternative entry site [1]. The authors have described a new technique which uses a direct optical entry method at Palmer's point (3 cm below the left costal margin in the midclavicular line) [2]. By doing this, one is allowed a visual inspection of the umbilicus and ensuing adhesiolysis to allow subsequent insertion of an umbilical port under direct vision. The authors have performed this technique on 15 patients and reported no entry-related complications. Periumbilical adhesions were seen in 12 of the 15 patients.

Method and findings

We recognise the need for an alternative laparoscopic entry method in order to avoid the risks mentioned above and in our practise, have employed Hasson's cut-down technique at Palmer's point. As the authors explained, Hasson developed the open-entry technique because of his discomfort when inserting needles and trocars blindly into the abdomen [2, 3]. The step-by-step process of Hasson's cut-down technique at Palmer's point applied by our team is as follows:

• Inspection for scars in left hypochondrium and palpation for hepatomegaly and splenomegaly, followed by exclusion of patients with these clinical signs

• 2-cm skin incision over Palmer's point

• Division of subcutaneous fat

• Incision of external aponeurosis with insertion of two vicryl 1 J-sutures onto fascia

• Splitting of transversalis muscle fibres

• Incision of internal aponeurosis

• Peritoneum picked up between two graspers, palpated to check for bowel and opened with knife

• Insertion of purse-string suture with 2° vicryl to peritoneum

• Placement of blunt-tipped trocar with sleeve into peritoneal cavity (aforementioned J-sutures hold the sleeve in place, and the purse string helps maintain a pneumoperitoneum)

Conclusion

We congratulate the authors on their case series, describing the use of a direct optical entry technique, using Palmer's point in gynaecological patients. This technique provides an alternative approach to the abdominal cavity, and we hope that our description of Hasson's cut-down technique, also through Palmer's point, offers an added method alongside closed and open umbilical techniques when performing laparoscopic gynaecological surgery.