Artin Ternamian

Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

OBJECTIVE To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. OPTIONS The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. OUTCOMES Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. EVIDENCE English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmers) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

A trocarless, reusable, visual-access cannula for safer laparoscopy; An update

A new instrument for laparoscopic access consists of a trocarless, reusable, visual-access cannula with an external thread that ends in a blunt tip. The device has no sharp ends or moving parts. The cannula does not transect but radially stretches and elevates vessels, fascia, and muscle fibers, preserving the fascias natural gridiron shutter mechanism at the access site. The outer thread stabilizes the cannula, and no fascial suture is necessary. In a prospective clinical trial between 1994 and 1997, the instrument was used in 203 patients requiring 234 access ports for diagnostic and operative laparoscopies. No device-related complications or failed attempts were recorded. The cannula caused less tissue trauma at access sites, and may decrease the frequency of hernias and postoperative access site pain.

Core competencies for gynecologic endoscopy in residency training: a national consensus project.

Residents and educators in obstetrics and gynecology have identified the need to improve endoscopic surgical education. The Canadian Endoscopy Education Project aims to create a national standardized endoscopy curriculum. The objective of the current project was to identify the core competencies for a gynecologic endoscopy (GE) curriculum in residency training programs. This expert consensus project (Canadian Task Force Classification III) included all 16 academic obstetrics and gynecology residency programs in Canada. Each university program selected their leading endoscopy educator to participate in the consensus process. Competencies for proficiency in GE were identified and then reviewed in 3 sequential rounds of consensus building using the Delphi technique. Overall, 213 objectives were reviewed and 199 (93%) of the items achieved consensus agreement. Competencies that were deemed outside the realm of general residency education were also collated and may represent a guide to subspecialty fellowship training in the future. The core competencies for GE training in obstetrics and gynecology residency were determined through national expert consensus. This provides the basis for a national standardized endoscopy curriculum for general obstetrics and gynecology training.

Laparoscopic entry: a review of Canadian general surgical practice

BACKGROUND Laparoscopic surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Although the overall risk of complications during laparoscopic surgery is recognized to be lower than during laparotomy, inadvertent serious complications still occur. Creation of the pneumoperitoneum and placement of laparoscopic ports remain a critical first step during endoscopic surgery. It is estimated that up to 50% of laparoscopic complications are entry-related, and most injury-related litigations are trocar-related. We sought to evaluate the current practice of laparoscopic entry among Canadian general surgeons. METHODS We conducted a national survey to identify general surgeon preferences for laparoscopic entry. Specifically, we sought to survey surgeons using the membership database from the Canadian Association of General Surgeons (CAGS) with regards to entry methods, access instruments, port insertion sites and patient safety profiles. Laparoscopic cholecystectomy was used as a representative general surgical procedure. RESULTS The survey was completed by 248 of 1000 (24.8%) registered members of CAGS. Respondents included both community and academic surgeons, with and without formal laparoscopic fellowship training. The demographic profile of respondents was consistent nationally. A substantial proportion of general surgeons (> 80%) prefer the open primary entry technique, use the Hasson trocar and cannula and favour the periumbilical port site, irrespective of patient weight or history of peritoneal adhesions. One-third of surgeons surveyed use Veress needle insufflation in their surgical practices. More than 50% of respondents witnessed complications related to primary laparoscopic trocar insertion. CONCLUSION General surgeons in Canada use the open primary entry technique, with the Hasson trocar and cannula applied periumbilically to establish a pneumoperitoneum for laparoscopic surgery. This surgical approach is remarkably consistent nationally, although considerably variant across other surgical subspecialties. Peritoneal entry remains an important patient safety issue that requires ongoing evaluation and study to ensure translation into safe contemporary clinical practice.

The past, present and future of minimally invasive endoscopy in gynecology: A review and speculative outlook

Abstract Over the last twenty-five years, minimally invasive surgery (MIS) has evolved in a relatively short period of time to overtake the centuries-old visionary and pioneering groundwork of our outstanding colleagues in all surgical disciplines. This overview on the development of gynecological endoscopy, at the invitation of SMIT, highlights past achievements and describes present challenges. It emphasizes future opportunities and possibilities to foster interdisciplinary collaboration and integrate emerging endoscopic, imaging and stereotactic surgical technologies to improve patient safety, enhance quality of care and advance surgical education. This article will introduce younger colleagues to the exciting world of contemporary gynecologic endoscopy and help them appreciate the immense technology-laden opportunities that the future holds for those who are prepared to follow in the footsteps and aspirations of our founding surgical colleagues.

Laparoscopic peritoneal entry with the reusable threaded visual cannula.

STUDY OBJECTIVE To estimate the feasibility, reproducibility, and safety of laparoscopic port establishment using a trocarless and externally threaded visual cannula (TVC). DESIGN Multicentre, prospective, observational study (Canadian Task Force classification II-2). SETTING Three university-affiliated teaching hospitals. PATIENTS Four thousand seven hundred twenty-four women (median age, 34 years; median body mass index, 25) underwent laparoscopic surgery. INTERVENTION After administration of general anesthesia, the Veress needle was inserted at the umbilicus or the left upper quadrant (LUQ) using Veress intraperitoneal pressure of 10 mm Hg or less as proxy for correct placement. Transient high intraperitoneal pressure of 20 to 30 mm Hg was attained, and primary and ancillary ports were established using the reusable trocarless TVC. MEASUREMENTS AND MAIN RESULTS Institutional research ethics board approval and patient consent for video capture were obtained. Primary umbilical entry was established in 4598 patients (97.33%), primary LUQ entry in 123 (2.60%), and primary suprapubic entry in 3 (0.06%) patients. Peritoneal preinsufflation was abandoned when 3 consecutive umbilical or LUQ Veress needle insertion attempts failed. Some patients at high risk with known peritoneal adhesions or previous lower abdominal midline scars did not undergo preinsufflation, and the trocarless TVC was applied directly. Surgery was postponed in 3 patients in whom insufflation failed, to enable further counseling and appropriate consenting. There were no serious abdominal wall or intraabdominal vascular injuries. One transverse colon, densely adhered to the umbilical region, was injured, which was recognized and repaired intraoperatively. Residents, fellows, or faculty recorded entry-related data on forms postoperatively for study and analysis. CONCLUSIONS Establishing peritoneal ports with the trocarless TVC is feasible, reproducible, and seems to be highly adoptable.

Principles of safe laparoscopic entry

Laparoscopy is now the preferred approach for performing diagnostic procedures and therapeutic interventions in gynaecology. Minimally invasive surgery is less disabling, reduced hospital stay and more cost effective to health care systems, when compared with conventional open operations [1–6]. Although the risk of major complications does not significantly differ between benign gynaecological laparoscopic and conventional open procedures, laparotomy has been associated with a 40% higher risk of minor complications [6]. Most often the risk of complications during laparoscopy occurs during initial entry into the abdominal cavity. The rates of life-threatening complications at the time of abdominal entry are low – 0.4 gastrointestinal iatrogenic injuries and 0.2 major blood vessel injuries per 1000 laparoscopies [7]. However these represent approximately 50% of all serious laparoscopic complications [8] and laparoscopic medico-legal litigations (http://www. piaa.us/LaparoscopicInjuryStudy/pdf/PIAA_2000). Minor complications include extra-peritoneal insufflation, which also occurs prior to the initiation of the intended surgical procedure, and postoperative wound infection. On reviewing the published literature (gynaecology, urology, general surgery), it appears that most practitioners use one of three blind primary entry methods to access the peritoneal cavity during laparoscopic surgery: (1) the closed (classic or Veress needle) technique, (2) the open (Hasson) technique, and (3) the direct trocar insertion described by Dingfelder in 1978 [9,10]. Variations of these three techniques such as visual entry systems and radially expanding trocars are less frequently utilized. Evidence based risk management methods can be applied to deconstruct the primary abdominal entry into its three distinctly separate, interdependent and salient components; entry methods, entry instruments and entry sites [11]. Based on currently available data, no one abdominal entry method appears to be generally considered superior over another and recommended as the technique of choice [2,12–14]. However, in the large majority of trials, there is a type II error to detect complications. Since the complication rates are low, most trials are inadequately powered to detect statistically significant differences between the comparison techniques. For example, to show a difference in bowel injury rate of say 50%, i.e.

Laparoscopic Abdominal Entry by the Ternamian Threaded Visual System

The word endoscopy is of Greek derivation in which endon means internal, and skopein means to examine. Healers from Hippocrates’ time have adapted primitive viewing instruments to peer into dark and yet-undiscovered body crevasses, in an attempt to understand and relieve human suffering [1]. Despite considerable technologic advancements, endoscopy retains three principal elements to accomplish its objective. The first comprises a flexible or rigid viewing tube endoscope to transmit light into the body cavity and convey back images for the surgeon to observe. The second consists of an array of ancillary surgical instruments to enable the operator to perform minimally invasive diagnostic and therapeutic tasks. The third is an anchored access system that leads instruments in and out of body compartments without loss of distention or orientation. These conduits (ports) are either surgically created temporary invariant entry points (thoracoscopy, laparoscopy, culdoscopy), through natural orifices, without requiring entry wounds (bronchoscopy, colonoscopy, hysteroscopy) or through contemporary hybrid conduits (Natural Orifice Transluminal Endoscopic Surgery [NOTES]).

Future Perspectives in Hysterectomy

This chapter reviews current practices as it relates to the commonest gynecological procedure performed: hysterectomy.

Instrumentation Systems, Apparatus and Materials in Hysterectomy

As the worldwide development and popularization of endoscopic surgery began for all medical disciplines with Kurt Semm in Kiel many instruments and apparatus have been designed primarily for gynecological endoscopic surgery in our department. It is our pleasure as contemporary witnesses to describe in this chapter instrument systems, apparatus and materials that have been developed over the past 45 years in cooperation with industry to facilitate the performance of precise endoscopic surgery today. Laparoscopic Hysterectomy has already a history of more than 25 years and basically uses all current instrumental developments including the electric loop for subtotal hysterectomy, modern thermofusion and ultrasound coagulation and cutting devices as well as the newest suturing technologies. Multiple and single port entries for hysterectomies are specified, the robotic approach and the use of articulated instrumental systems are detailed in other chapters.