Page 14 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

CHAPTER 6: Abdominal Access Techniques 13

In same manner, all the working port should be valve. Several cannulas modeled on the Hasson cannula
introduced, and instruments are inserted to start the is available for use during open laparoscopic procedures.
surgery (Fig. 34). It should be remembered that distance Different sized converters (gaskets) are available for
between two ports should never be <5 cm. The “Baseball disposable cannula to maintain the gas seal.
diamond concept” discussed in next chapter is the most
appropriate method to decide the site of introduction OPEN ACCESS
of working port. The positioning of operative ports is an Open access technique was developed by Hasson in 1974
important factor in determining the ease with which a (Figs. 35 to 41). The choice of site may be based on the
procedure is carried out. It is a skill which must be learnt. surgeon’s preference or the presence of a previous regional
incision that may have adhesions. Hasson trocar is used in
Slipping of Port open technique which is available both in disposable and

Sometimes, the port wound becomes bigger than the reusable model (Figs. 35 and 36). Open access technique is
diameter of cannula and it tends to slip out frequently. like minilaparotomy and the cannula is introduced inside.
In these situations, a simple stitch over skin and fixing of Hasson’s technique involves direct open visualization of
the cannula with the help of sterile adhesive tape helps. the tissues at every layer until the peritoneum is opened,
In pediatric laparoscopic surgery, stabilizing the port is followed by placement of anchoring sutures in the fascia
necessary. Reusable metal cannula has trumpet or flap to secure a conical collar. The trocar is then placed
valves. The flap valves can be manually opened when through the collar to establish pneumoperitoneum and
introducing or removing an instrument. This avoids access. Disadvantages include persistent uncontrolled
damaging delicate instruments such as tip of telescope CO leakage in many cases, increased incision size, and
2
or blunting sharp instruments such as aspiration needle increased time for placement. This technique generally
and scissors. A reducer tube is used with large cannula adds to the length of the procedure, taking longer to
to maintain the gas seal and this automatically opens the perform at the beginning and the end of the procedure

Fig. 31: Initial diagnosis of injury after access. Fig. 32: Introduction of secondary port.

Fig. 33: Introduction of secondary trocar. Fig. 34: All the ports and instruments should be positioned properly
without entangling each other.