Page 27 - Journal of WALS

Anaam Majeed Hasson

normotensive and maintain respiratory pressures at 30 to that the open entry technique is superior to or inferior to the
40 mm Hg during the Tilt test before and after insufflation are other entry techniques currently available.
very likely to have a positive clinical result. 16 The visual entry cannula system may represent an
The role of alternative peritoneal access has been evaluated advantage over traditional trocars, as it allows a clear optical
by a retrospective review of 918 insufflations through the 9th entry, but this advantage has not been fully explored. The visual
intercostal space which found one entry into the stomach and entry cannula trocars have the advantage of minimizing the size
one into the pleural space (causing a pneumothorax) by the of the entry wound and reducing the force necessary for
Veress needle. insertion. Visual entry trocars are nonsuperior to other trocars
Transuterine Veress CO insufflation using a long Veress since they do not avoid visceral and vascular injury. 15
2
needle for pneumoperitoneum has been found to be especially To identify which of the various laparoscopic entry
helpful in obese women. In one study of 138 women weighing techniques is the safest and/or most effective in the obese
250 to 400 lbs, failure to establish pneumoperitoneum occurred woman undergoing gynecological laparoscopic surgery, Sarah
in 13.8% (5/36) through the umbilicus, in 3.6% (3/83) through and Josette (2008) reviewed seven individual studies (Fig 2),
the uterus, in 8.3% (1/12) subcostally and in 28.6% with a total target population of 461 obese women, BMI across
(2/7) through the open (Hasson) technique. A prospective selected studies ranging between 28 and 44 (Fig. 3), who
randomized study compared the conventional infraumbilical underwent five different laparoscopic methods of entry
route with a transuterine route in 100 overweight and obese
2
women (BMI > 25 kg/m ) in establishing pneumoperitoneum. In
the infraumbilical group, pneumoperitoneum was achieved at a
ratio (punctures/pneumoperitoneum) of 56/49 (1.14) with one
failure, but in the transuterine group the ratio was 53/51 (1.04). 15
Similar results were obtained by Wolfe et al. 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. 24
Several studies on the benefits and complications of the
various laparoscopic entry techniques have been published.
Hasson reviewed 17 publications of open laparoscopy by
general surgeons (9 publications, 7,205 laparoscopies) and
gynecologists (8 publications, 13,486 laparoscopies) and
compared them with closed laparoscopy performed by general Fig. 2: Number of obese women in selected studies (n = 461)
surgeons (7 publications, 90,152 patients) and gynecologists
(12 publications, 5,79,510 patients). Hasson reported that for
open laparoscopy the rate of umbilical infection was 0.4%, bowel
injury 0.1% and vascular injury 0%. Hasson advocated the open
technique as the preferred method of access for laparoscopic
surgery. Further analysis of Hasson’s review suggests that the
prospective studies and surveys indicate that general surgeons
experience higher complication rates than gynecologists with
the closed technique, but experience similar complication rates
with the open technique. Using the closed technique, the visceral
and vascular complication rates were 0.22 and 0.04% for general
surgeons, and 0.10 and 0.03% for gynecologists. In a published
record of his own 29-year experience with laparoscopy in 5,284
patients, Hasson reports only one bowel injury within the first
50 cases.
The open entry technique may be utilized as an alternative
to the Veress needle technique, although the majority of Fig. 3: Range of BMI across selected studies
gynecologists prefer the Veress entry. There is no evidence (with mean where possible)

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