Page 36 - WJOLS - Laparoscopic Journal

Mandavi Rai
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he intends to use. This indicates that in spite of the or splenic surgery or palpable gastropancreatic mass.
improve ment in the technology and experience, primary A 5 mm telescope can be introduced at the same site of
access complications were decreased but not completely Veress needle visualize the periumblical adhesions, then
eliminated. a 10 mm trocar can be introduced under direct vision,
The included techniques (Veress needle pneumo­ followed by additional trocar/cannula system inserted
pertonium, trocar/cannula system). Open (Hasson) under direct vision as required. Therefore, the angle of
technique. Direct trocar insertion without prior pneumo­ Veress needle insertion should vary accordingly from
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peritoneum. The use of shielded disposable trocars. Opti­ 45º in nonobese women to 90º in very obese women.
cal Veress needle and optical trocar. Radically expanding Several tests have been recommended to ascertain correct
trocar and the trocarless, reusable visual access cannula. 4 placement of Veress needle in the peritoneal cavity.
These include:
MATERIALS AND METHODS • Double click sound of the Veress needle test
• Aspiration test
A Literature review was performed using PubMed, Med • Hanging drop of saline test
Space, Springer Link and search engines like Google • Syringe test. 8
and Yahoo. Following search terms were used: trocar, A recent retrospective study evaluating these four
laproscopy, complications and pneumoperitoneum, entry tests reported that non of four tests proved confirmatory
technique. Total of 10,000 citations were found. Selected for the intraperitoneal placement of the Veress needle and
papers were screened for further references. Publica­ concluded that the most valuable test is to observe actual
tions that featured illustrations and statistical methods insufflation pressure (intraperitoneal) to be 8 mm Hg
of analysis are selected. or less, and the gas is flowing freely. It has been shown
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that achieving high intraperitoneal pressure (HIP) entry
Different Laparoscopic Entry or ranging from 20 to 25 mm Hg will increase the gas
Access Techniques bubble and produce greater splinting of the anterior

Veress Needle and Pnemoperitoneum abdominal wall and increase the distance between the
umbilicus and bifurcation of the aorta from 0.6 cm (at
Veress needle was first popularized by Roal Palmer of pressure of 12 mm Hg) to 5.9 cm. This will allow easy
France 1947. The creation of pneumoperitoneum remains entry of the primary trocar and minimize the risk of
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an essential step of successful laparoscopic surgery. vascular injury. The high pressure entry technique
Being a blind procedure, it is associated with injury is recommended by the Royal College of Obstetricians
to the vascular and visceral contents of the peritoneal and Gynaecologists (RCOG), London and The Society of
cavity. It is the most popular technique used by most Obstetricians and Gynaecologists of Canada (SOGC). 11,12
of the laparoscopic surgeons worldwide to achieve New modifications to the Veress needle have been
pneumoperitoneum. There are many sites for insertion introduced to minimize Veress needle associated
for Veress needle to achieve pneumoperitoneum. In the injury. These include pressure sensor equipped Veress
usual circumstances in a patient with an average body needle, optical Veress needle. However, none of these
mass index (BMI) and no history of previous or suspected new modifications has been proved to be superior
intraperitoneal adhesions, the Veress needle is inserted to the classic Veress needle and eliminated Veress
through an incision at the base of the umbilicus. In obese needle­related injury. Controlled randomized trials are
patient with BMI > 30 or patient with history of previous recommended to ascertain their safety and justify their
midline incision, or failed pneumopertonium after three extra cost (Fig. 1). 13
attempts alternative site for Veress needle insertion may
be thought. The second common site for insertion of Hassons Method
Veress needle is the Palmer’s point which lies 3 cm below Hasson (open) entry technique was first described by
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the left costal border in the midclavicular line. This Harrith Hasson in 1971. When first reported his technique
technique is recommended for obese or very thin patient, Hasson claimed that his technique avoids Veress needle
patient with history of previous midline surgery or pneumoperitoneum and its associated complications (gas
suspected intraperitoneal adhesions, or failure to achieve embolism and vascular injury). This technique involves
pneumoperitoneum after three attempts. It is essential to incising the fascial layer and holding its edges by two
decompress the stomach using nasogastric tube suction. lateral stay sutures, these will be used to stabilize the
This technique should be avoided in patient known to cannula. This will seal the abdominal wall incision to
have hepatosplenomegally, history of previous gastric the coned­shape sleeve. The telescope is introduced and
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