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Laparoscopic insufflation through a defined surgical point in the left upper quadrant: A 3-year experience
Abstract
Laparoscopic surgery is frequently performed in gynaecology for a variety of indications. The most important step in laparoscopy
is the creation of pneumoperitoneum and safe placement of the primary trocar. Initial entry with a Veress needle for CO2 insufflation was performed through the left upper quadrant, at the height of the dome of the lower margin of the sub-costal
region. In the majority of cases, a single entry was successful in achieving CO2 insufflation. No visceral injury was noted with our technique in 442 laparoscopic procedures. This surgical landmark provides
several advantages over other entry points and was feasible in 442 laparoscopies, irrespective of the patient characteristics,
such as age, body mass index (BMI), previous surgical history and operative indications.
... Initial entry with Verres needle for CO 2 insufflation was performed through the left upper quadrant, at the height of the dome of the lower margin of the left sub-coastal region. Verres needle is passed perpendicularly by the margin of the sub-coastal region with an initial pressure of 25 mmHg; as it traverses the abdominal layers, the pressure increases to 50 mmHg, and once it breaches the peritoneal layer, the pressure immediately drops to <9 mmHg high/free flow of the gas [3]. After successful pneumoperitoneum, the first 10-mm port is placed in the left upper quadrant. ...
In this case series, six women with high and very high body mass index (BMI; range, 30–65) underwent LAVH + bilateral salphingo-ophorectomy
and removal of vaginal cuff under general anaesthesia for endometrial cancer. Initial Verres needle entry and insufflation
was through the left upper quadrant at sub-coastal margin. With good surgical outcome, shorter hospitalisation and improved
quality of life, we found that laparoscopic surgery was feasible in high and very high BMI patients with early stage endometrial
cancer.
Because induction of artificial pneumoperitoneum through the infra-umbilical route is associated with complications in laparoscopic
procedures, especially in obese patients, we performed a prospective randomized study comparing the conventional infra-umbilical
route with a transfundal route, in which the Veress needle is inserted into the peritoneal cavity through the uterine fundus.
One hundred obese subjects (body mass index ≥25 kg/m2) scheduled for laparoscopic sterilization were randomized into two groups. In the infra-umbilical group pneumoperitoneum
was achieved at a ratio (punctures/pneumoperitoneum) of 56/49 (1.14). There was one failure in this group. In the transfundal
group the ratio was 53/51 (1.04). There was no clinically significant bleeding in either of the groups; nor were there any
major complications. One subject in whom the infra-umbilical route failed was moved to the transfundal group. This subject
also underwent dilatation and curettage at the time of laparoscopy. Postoperatively she contracted chlamydial pelvic inflammatory
disease. No other infections were detected postoperatively in either of the groups. In conclusion, the transfundal route of
inducing artificial pneumoperitoneum proved to be easy, safe and effective.
The aim of this study is to evaluate the prevalence of intraabdominal adhesions to the umbilicus following gynecologic laparoscopy through an umbilical incision.
A retrospective review was performed of all gynecologic laparoscopic procedures in a private practice setting to identify patients with a repeat laparoscopy who had a history of a previous laparoscopy through an umbilical incision. Patients with a history of other surgeries were excluded. All repeat laparoscopies used a left upper quadrant entry technique where the abdominal cavity was surveyed for adhesions. We also reviewed adverse events attributable to the left upper quadrant entry approach.
We identified 151 patients who underwent a second laparoscopy and had a previous umbilical scar. Thirty-two of the 151 (21.2%) patients with a history of a laparoscopy had evidence of adhesions to the umbilical undersurface. No adverse events or injuries were attributed to the left upper quadrant entry technique.
Adhesions to the umbilical undersurface occur in 21.2% of patients who have undergone a prior laparoscopy through an umbilical incision. For this reason, we recommend an alternate location for entry in patients with an umbilical scar from a previous laparoscopy.
Addresses the theoretical basis of science and is not just "watered-down Biology" Explains the most complex issues in a clear and non-technical manner Emphasizes the accessibility of scientific thinking and the excitement of science even to students who have feared or disliked what they considered to be science Relates the development of scientific ideas to their cultural context Emphasizes process rather than data, and encourages students to think and analyze Prepares students to cope with today's barrage of scientific information and argument Prepares students to comprehend and cope with the rapid changes that continually occur in science Presents without polemic the scientific case for belief in evolution and natural selection This book, by a practicing and successful scientist, explores why questions arise in science and looks at how questions are tackled, what constitutes a valid answer, and why. The author does not bog down the reader in technical details or lists of facts to memorize. Instead, he places the questions in their historical and cultural context, ranging from the earliest intimations that the earth had a long history to current controversies, even describing the origins, challenges, and promises of modern molecular biology. Addressing issues as complex as radiocarbon dating and how we know that DNA is a double helix, he uses examples, illustrations, and descriptions that all students should be able to grasp ("Were there kangaroos in Noah's Ark?"; "Molecular Biology Ain't Rocket Science"). He gives the reader a sense of why a scientist feels always "like the child called to the stage to watch the magician do his trick". The author's thesis is that scientific logic is an extension of the common human logic used by everyone on a daily basis, and that it can and should be understood by everyone.
Face-to-face assessment within 1 hour after placing a patient in a restraint has been the standard of care following regulatory requirements set forth by the federal government in 1999. This rule, although widely followed and applauded as optimum patient care, has little evidence of a standardized format for what constitutes the examination. Health care providers agree that a face-to-face assessment is warranted; however, no set parameters exist for what constitutes the key elements of such an assessment. This clinical practice guideline offers a specific outline to follow that emphasizes the safety of the patient being placed in a mechanical restraint for a behavioral health emergency.
A woman in her mid-40s with a body mass index (BMI) of 70 presented with lower abdominal pain of 24-h duration. The trans-abdominal
scan revealed a large cystic ovarian mass. Laparoscopic salpingo-oophrectomy was performed by placing six ports in the upper
abdomen; initial Verres needle entry and pneumoperitoneum were established through the left upper quadrant. A low CA-125 and
the benign appearance of the ovary allowed the operation to continue laparoscopically with fewer perioperative complications.
The histology of the specimen demonstrated a benign epithelial serous cystadenoma of the ovary with torsion.
A pneumoperitoneum separating the anterior abdominal wall from the intraperitoneal organs is essential to view the pelvic organs and to perform laparoscopic surgery. A Veress needle was inserted through the uterine fundus to establish a pneumoperitoneum in 100 women undergoing laparoscopy for sterilization or diagnostic purposes. The transuterine approach was chosen for 86 women because of obesity and for 14 because a previous abdominal insertion had been unsuccessful. There were no complications associated with the transuterine Veress needle placement. This method should be considered for obese patients and for those women in whom the transabdominal approach is unsuccessful.
Since 1977, routine cul-de-sac insufflation to achieve a pneumoperitoneum for laparoscopy was performed on 350 women under local anesthesia. A van Schie/van Lith intrauterine tenaculum, used together with a self-retaining Trelat speculum, guaranteed maximum stretching of the posterior vaginal fault and fixation of the anteflexed uterus necessary for an accurate 1-cm deep penetration of a pneumoperitoneum needle into the cul-de-sac. The correct position of the tip of the needle was determined precisely by means of two manometers. The failure rate in the first study of 195 procedures was 3.6% and that in the following 155 cases was 1.9%. There were no serious operative complications. The authors recommended the cul-de-sac insufflation approach for inducing pneumoperitoneum as the technique of choice.
To assess the safety and efficacy of different insufflation methods in morbidly obese women undergoing laparoscopy.
Retrospective analysis of 13 years' experience (Canadian Task Force classification II-2).
University-affiliated hospital.
One hundred thirty-eight morbidly obese women (weight >250 lbs, body mass index >36). The heaviest patient weighed 400 lbs and had a body mass index of 66.
Laparoscopic tubal sterilizations and diagnostic laparoscopies performed on an outpatient basis by residents under faculty supervision.
Of 138 patients, 36 underwent standard transumbilical insufflation with 5 failures, 83 had transuterine insufflation with 3 failures, 12 had subcostal insufflation with 1 failure, and 7 had open laparoscopy with 2 failures.
The insufflation failure rate was significantly high for transumbilical insufflation and open laparoscopy, and not for transuterine or subcostal insufflation. Morbid obesity was not a contraindication to laparoscopy. (J Am Assoc Gynecol Laparosc 6(3):307-312, 1999)
To determine the anatomy of the left upper quadrant (LUQ) of the abdomen in women with different body mass indexes.
Review of computed tomographic (CT) scans and medical records (Canadian Task Force classification II-2).
Large tertiary care medical center.
Sixty-three women over age 18 years who had scans performed for any indication. Nine women were excluded because of contraindication to LUQ laparoscopic cannula insertion and five because of incomplete records. Intervention. None.
The closest organs to the LUQ insertion site were the liver and stomach. There was significantly more subcutaneous fat at the umbilicus than at the insertion site. A positive correlation was found between body mass index and distance between structures and the site.
Cannulas should not be inserted in the LUQ in women with hepatomegaly or splenomegaly. Because the stomach is so close to the insertion site, gastric drainage should be performed before cannula insertion. The site is likely safe in obese women whose abdominal organs are far away from it, and who have less subcutaneous fat there than at the umbilicus.
We used the middle upper abdomen as a primary port insertion as an alternative portal for laparoscopy and multiport operative pelviscopy in 188 women who were at high risk for subumbilical adhesions because of previous abdominal surgeries or history of gynecologic cancer. Primary cannula insertion was in the middle upper abdomen between xyphoid process and umbilicus (Lee-Huang point). This was the single entry site for the Veress needle and primary laparoscopy port. In 184 (98.4%) of 188 women surgery was performed without complications. No procedure was converted to laparotomy due to visceral or vascular injuries. Two omentum injuries from primary port insertion were repaired with bipolar electrocoagulation; a colon injury was repaired with laparoscopic sutures. In our experience, this laparoscopic port is effective in women who have had abdominal surgery or gynecologic malignancy. (J Am Assoc Gynecol Laparosc 8(1):147-150, 2001)
Surgeons performing sophisticated endoscopic operations must be well versed in alternate laparoscopic access methods to address evolving patient expectations and safety requirements. The safety of left upper quadrant laparoscopic entry in patients with prior surgeries and abdominal adhesions was evaluated. Laparoscopic surgery was performed for various indications on patients with prior surgical scars and anticipated risk of adhesions at the primary umbilical port site. All laparoscopies performed from July 1998 through June 2004 were analyzed. Of the 918 laparoscopies, 504 patients (54.9%) were found to have involvement of their umbilicus with adhesions that could have affected the traditional umbilical primary port entry. Left ninth intercostal space was used for Veres needle entry, and the primary trocar was placed in the left upper quadrant space. Of the 504 potentially risky entries, there were two (0.39%) Veres-needle related and zero trocar-related injuries. All surgical procedures were accomplished laparoscopically, and all entries were accomplished by the left upper quadrant entry technique. Therefore left upper quadrant entry technique is a safe and easily learned alternate access technique.
The use of the left upper quadrant technique in establishing a pneumoperitoneum during gynecologic laparoscopy was reviewed retrospectively in 267 patients who underwent gynecologic laparoscopy. The study population included all patients presenting to the University of Louisville Hospital outpatient surgery unit for laparoscopic gynecologic surgery from January 1994 to March 2002. Data sheets were prospectively compiled for each patient that included their demographics as well as the intraoperative insufflation technique used and the number of attempts necessary to achieve successful insufflation. All recognized complications associated with establishment of the pneumoperitoneum or insertion of the primary trocar were recorded. The database included 3314 patients of which 267 underwent insufflation via the left upper quadrant technique. Failure to achieve insufflation using this technique occurred in 4 patients (1.5%). There were no bowel or vessel injuries. Puncture of the left lobe of the liver occurred in 3 patients (1.12%). All injuries were managed without laparotomy, and the patients fully recovered without sequelae. The left upper quadrant entry technique is an effective means of establishing a pneumoperitoneum in patients undergoing gynecologic laparoscopic procedures.
Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.
Prospective observational cohort study (Canadian Task Force classification II-1).
University affiliated teaching hospital.
We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.
Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.
The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.
A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.
Our objectives were to assess the safety and efficacy of different insufflation methods in women undergoing laparoscopy and to develop a model for selection of the appropriate insufflation technique based on the patient's characteristics and surgeon's experience. We performed a retrospective analysis of laparoscopic procedures on 3086 women over a 13-year period at the University of Louisville Hospital, Louisville, KY. All laparoscopic procedures were performed on an outpatient basis by residents under faculty supervision. Five different insufflation techniques were evaluated: standard transumbilical insufflation, open laparoscopy, transuterine insufflation, subcostal insufflation, and direct trocar insertion technique. Body mass index and previous abdominal surgeries were identified as the most important factors in the selection of the most successful insufflation method based on the surgeon's experience, using data mining techniques. During the first insufflation attempt, we were successful at achieving a pneumoperitoneum 94.7% of the time. This number increased to 98.1% when we switched to a second alternative insufflation method. In all, there were 5 complications out of 3086 patients (0.16%) after all insufflation techniques.
It is well known that at least 50% of laparoscopic complications occur during the initial entry into the abdomen regardless of the method used. There is evidence that most gynecologists practice the "classic" or closed laparoscopic entry. There is no evidence that the closed entry is more or less dangerous than the other existing methods of entry. Entry-related complications have been minimized by the following three steps: low initial Veres intraperitoneal pressure indicating correct placement of the Veres needle; transient high-pressure pneumoperitoneum before primary trocar/cannula insertion; and visual entry with the Ternamian cannula. Following the above steps, no entry complications have been encountered by the author in more than 3000 consecutive laparoscopies.
SOGC clinical practice guideline
- G A Vilos
- T Artin
- A Temamian
- P Y Laberge
- GA Vilos
Vilos GA, Artin T, Temamian A, Laberge PY (2007) SOGC
clinical practice guideline. J SOGC 193:433-447