Page 25 - Journal of WALS
P. 25

Anaam Majeed Hasson
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          procedure.  The frequency of entry complications reported in  women. Insertion at 45°, even from within the umbilicus, means
          the international literature is very low (1-3%). The most serious  that the needle has to traverse distances of 11 to 16 cm, which
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          complications may be life-threatening, but are very rare with  is too long for a standard Veress needle.  Using MRI and CAT
          the incidence of major vascular perforation reported as being  scans (on unanesthetized women in the supine position) to
          0.9 per 1000 procedures and the incidence of bowel perforation  measure the thickness of the abdominal wall and critical
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          reported as being 1.8 per 1000 procedures.  Even if the reported  distances to the great vessels. Hurd et al reported that the
          prevalence is very low, the mortality rate arising from these  position of the umbilicus was found, on average, 0.4, 2.4 and 2.9
          lesions reportedly ranges between 8 and 17%. 13     cm caudally to the aortic bifurcation in normal weight (BMI < 25
                                                                                             2
                                                                  2
                                                              kg/m ), overweight (BMI 25-30 kg/m ) and obese (BMI >
                                                                    2
          Challenges with the Laparoscopic                    30 kg/m ) women respectively (Fig. 1). In all cases, the umbilicus
          Entry Techniques in Obese                           was cephalad toward the left common.
          Although abdominal thickness correlates with patient weight,  Iliac vein crossed the midline at the sacral promontory.
          short stature or truncal obesity may increase abdominal wall  Preperitoneal placement and vascular injury with a standard
          thickness out of proportion to patient weight. Routine  Veress needle (11.5 cm in length) is least likely using the
          evaluation of the abdominal wall prior to laparoscopy is  standard approach in nonobese women. In the overweight
          important because the success of trocar insertion may depend  patient, however, similar outcomes require modifying the point
          on altering the technique based on abdominal wall thickness. 7  of needle insertion to the base of the umbilicus. Preperitoneal
             Standard gynecologic laparoscopic entry is through the  insufflation is least likely to occur in very obese women only if
          umbilicus. Blindly passing a sharp Veress needle, insufflating,  the needle is placed through the base of the umbilicus at a
          and then blindly passing a sharp trocar is the traditional  90º angle. The fact that the umbilicus is usually caudal to the
          technique for laparoscopic entry. Although it has been  bifurcation in this weight group helps support the relative safety
          suggested that the angle of Veress needle entry should vary  of this modified approach. 14,15
          between 45º and 90º according to the BMI of the patient, it is  Moreover, the saline drop test should be used to confirm
          reasonable to state that, for obese, a controlled 90º angle entry  intraperitoneal Veress needle placement. Entry related
          of the Veress needle with insertion of not more than 2 cm of the  complications may be reduced by filling the peritoneal cavity
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          needle tip with selective umbilical stabilization or elevation of  with carbon dioxide (CO ) to a predetermined pressure level
          the abdominal wall is the safest route of Veress needle insertion  rather than to a preset volume. Trocars may be placed angled
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          for the vast majority of cases.  The angle of insertion is more  towards the operation site to avoid torquing the instruments.
          critical as the adipose layer limits free rotational movement of  They can be sutured in place to prevent slippage and longer
          working ports. Patients who are grossly obese are at a  cannulas should be used. Finally, long instruments and extra
          significantly greater risk of complications when undergoing  ports along with routine bowel preparation will improve bowel
          laparoscopic surgery. In most women, the aortic bifurcation  manipulation, decrease bowel excursion into the operative field
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          rests between the 4th and 5th lumbar vertebrae, or within  and ultimately better visualization.
          1.25 cm above or below a line drawn between the iliac crests.  Alternative methods of entry for insufflation may be required
          Nevertheless, due to anatomic variation it may be located either  when faced with the very obese patient or when conventional
          above or below these disk spaces. The umbilicus is most  methods are contraindicated or fail to produce an adequate
          commonly located between the 3rd and 4th lumbar vertebrae.  pneumoperitoneum. Accordingly, the initial entry can also be
          However, this relationship is quite variable. The position of the  performed through other sites in the abdominal wall, as 9th or
          umbilicus relative to the aortic bifurcation is negatively  10th intercostal space or upper-left quadrant insertion site
          correlated with body mass; it more commonly rests caudal to
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          the bifurcation in overweight and very obese women.  If a
          Veress needle approach is used in the patient who is morbidly
          obese, an ultralong Veress needle may assist, also it is important
          to make the vertical incision as deep as possible in the base of
          the umbilicus, since this is the area where skin, deep fascia and
          parietal peritoneum of the anterior abdominal wall will meet. In
          this area, there is little opportunity for the parietal peritoneum
          to tent away from the Veress needle and allow preperitoneal
          insufflation and surgical emphysema. If the needle is inserted
          vertically, the mean distance from the lower margin of the
          umbilicus to the peritoneum is 6 cm (± 3 cm). This allows
          placement of a standard length needle even in extremely obese  Fig.1: Effect of obesity on location of great vessels

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