One of the great inventions in the history of laparoscopy has been the invention of Veress needle. Introduction of a needle into the peritoneal cavity to insufflate gas which was considered to be a risky procedure was made 'safe' by this spring loaded needle. Complications decreased and perhaps laparoscopy became much more popular after this invention. But is this needle really so safe as to use it without any complications al all? Review of literature in the 70s and 80s show that almost 70 to 80% of all complications of laparoscopy are related to the introduction of the Veress needle or the primary trocar into the abdominal cavity.
In fact there has been a continual improvisation in the type of trocars that have been used for the first blind entry, but they have all proved to be either associated with enough complications or have been an expensive proposition.
Almost two decades ago Harith Hasson in U.S.A., described open laparoscopy, which actually meant opening the peritoneum and visually introducing a blunt trocar-canula into the abdomen. Several specialists transformed their procedure to 'Hasson's technique', but several more remain faithful to the Veress needle. It is surprising that though Hasson himjself is a gynaecologist, more surgeons all over the world use open laparoscopy and gynaecologists have somehow remained averse to it.
Most gynaecologists, over the last decade or so have remained experts in laparoscopy in our country, thanks to the thousands of laparoscopic sterilizations they have had to perform. The scenario is fast changing. With more and more specialists and centers coming up the exposure each one gets is being minimised. We have patients coming for repeat surgeries much more often toady. With the advent of video-laparoscopy there is hardly any gynaecological surgery that needs a laparotomy. The risk of adhesions in repeat surgeries tilts the balance against the blind introduction of the Veress needle or the trocar. With increase inflammatory conditions, we need not have adhesions only in patients with previous surgeries but also in 'so-called normal' individuals. The answer to safe practice of laparoscopy is certainly open laparoscopy and this is becoming more and more obvious.
Open laparoscopy means introduction of the trocar into the peritoneal cavity after dissection and incision of the peritoneum and visualization of the abdominal cavity. This technique prevents 3 blind procedures:
- Introduction of Veress needle
- Insufflation of Carbon dioxide gas through the needle.
- Introduction of the trocar
It is only after these three blind procedures that we introduce a telescope and are able to ensure whether there was any damage done or not.
The procedure of open laparoscopy can be made easy by having a few small but very useful instruments as a set with our laparoscopic instruments. These include 2 small sized Allis (4 inch length), 2 straight artery forceps, 2 mosquito forceps and a pair of small right angled retractors. I generally use Ethibond or P.D.S. suture material, as this can be conveniently used to close the fascial defect at the end of the surgery.
A subumbilical incision is taken by stretching the abdominal skin downwards, so that the incision actually becomes intra-umbilical to give a better cosmetic scar. This is a curved incision of 1½ to 2 cms. length, a longer incision being taken in an obese patient. The upper skin flap is grasped with the small Allis forceps and retracted upwards and the lower flap is retracted down using a small retractor. The subcutaneous tissue is dissected from the umbilicus and the rectus sheath. The rectus sheath is grasped with another Allis forceps in the midline and two stay sutures are taken, on either side. With traction on the stay sutures, a vertical incision is made in the rectus sheath. A mosquito forceps is used to separate the rectus muscles and the peritoneum is grasped and held up in two mosquitoes. A very small incision is made in the peritoneum and after making sure that no other tissue is being injured this incision is increased and a blunt trocar-cannula to prevent any gas leak. Carbon dioxide gas insufflation is then started. This can be done more rapidly and time lost in dissection is made up. It is also possible to take a purse-string suture around the peritoneal incision instead of the stay sutures, and tie it around the introduced trocar. At the end of the surgery, fascial closure is facilitated by the fact that the introduced trocar. At the end of the surgery, facial closure is facilitated by the fact that the rectus sheath was dissected well earlier, and also because the incision tends to be slightly bigger. Cosmetic results have been almost the same as that with the use of Veress needle and sharp trocar, though the incision is about ½ cm bigger.
It is important to note that whatever the experience of the surgeon may be, the safety of blind introduction of the Veress needle and the trocar cannot be ensured as much as with open laparoscopy.
References[edit | edit source]
- Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2008(2):CD006583.
- Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971;110(6):886-887.
- Trocars: safety and selection. Emergency Care Research Institute. Health Devices. 1998;27(11):376-399.
- Hasson HM, Rotman C, Rana N, Kumari NA. Open laparoscopy: 29-year experience. Obstet Gynecol 2000;96(5 Pt 1):763-766.
- Mac Cordick C, Lecuru F, Rizk E, et al. Morbidity in laparoscopic gynecological surgery: results of a prospective single-center study. Surg Endosc 1999;13(1):57-61.
- Yuzpe AA. Pneumoperitoneum needle and trocar injuries in laparoscopy. A survey on possible contributing factors and prevention. J Reprod Med 1990;35(5):485-490.
- Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc 2001;8(3):341-347.
- Chapron CM, Pierre F, Lacroix S, Querleu D, Lansac J, Dubuisson JB. Major vascular injuries during gynecologic laparoscopy. J Am Coll Surg 1997;185(5):461-465.
- Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc 1996;6(5):367-370.
- Nezhat C. Operative Gynecologic Laparoscopy: Principles and Techniques. New York: McGraw-Hill, 1995:79-96.
- Brill AI, Nezhat F, Nezhat CH, Nezhat C. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol 1995;85(2):269-272.
- Yin L, Witten C, Neidelman S. Letter to manufacturers of laparoscopic trocars. In: FDA, Center for Devices and Radiological Health, Rockville, MD, Aug 23, 1996.
- Bonjer HJ, Hazebroek EJ, Kazemier G, et al. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 1997;84(5):599-602.
- Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc Percutan Tech 2005;15(3):119-123.
- Pasic RP, Kantardzic M, Templeman C, Levine RL. Insufflation techniques in gynecologic laparoscopy. Surg Laparosc Endosc Percutan Tech 2006;16(1):18-23; discussion 23-14.
- Chapron C, Cravello L, Chopin N, et al. Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications. Acta Obstet Gynecol Scand 2003;82(12):1125-1129.
- Hanney RM, Carmalt HL, Merrett N, Tait N. Vascular injuries during laparoscopy associated with the Hasson technique. J Am Coll Surg 1999;188(3):337-338.
- Wherry DC, Marohn MR, Malanoski MP, et al. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg 1996;224(2):145-154.
- A consensus document concerning laparoscopic entry techniques: Middlesbrough, March 19 - 20 1999. Gynaecol Endosc 1999;8(6):403-406.
- Ballem RV, Rudomanski J. Techniques of pneumoperitoneum. Surg Laparosc Endosc 1993;3(1):42-43.
- Hurd WW, Randolph JF, Jr., Holmberg RA, et al. Open laparoscopy without special instruments or sutures. Comparison with a closed technique. J Reprod Med 1994;39(5):393-397.
- Perone N. Laparoscopy using a simplified open technique. A review of 585 cases. J Reprod Med 1992;37(11):921-924.
- Gordon S, Maher P, Seman E. Open laparoscopy utilizing either a 5 mm or 10 mm standard intra-umbilical trocar. Gynaecol Endosc 2001;10(4):249-252.