Page 15 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

14 SECTION 1: Essentials of Laparoscopy

compared with a closed Veress needle technique. Even Steps of Open Access Technique
though the Hasson technique is most commonly used A transverse incision is made in the subumbilical region
in the periumbilical region, this method can be used and the upper skin flap is retracted with an Allis forceps.
anywhere on the abdominal wall and is particularly useful The lower flap is retracted using a small right-angled
when there is a concern for abdominal wall adhesions in a retractor. Subcutaneous tissue is dissected till the linea
patient with a prior laparotomy. alba and the rectus sheath is visualized. Stay sutures are
In this, there is a direct entry by open technique, taken on either side of the midline.
without creating pneumoperitoneum and insufflator is ■ ■Make a transverse or longitudinal incision in the skin
connected once blunt trocar is inside the abdominal cavity just below the umbilicus (Fig. 37).
under direct vision. There are various ways of open access ■ ■Stay suture is given both the end of transverse incision.
such as Hasson’s technique, Scandinavian technique, ■ ■Both the stays are pulled up to make a bridge-like
and Fielding technique. elevation of rectus.
Some surgeons and gynecologists practice blind trocar ■ ■Rectus sheath is incised in the midline along the line
insertion without pneumoperitoneum. The incidence of linea alba pointing upward. Incision should not
of injury due to this type of access is much higher. This penetrate the peritoneum; otherwise any adhesion
type of direct trocar entry is practiced by gynecologists with the peritoneum may be punctured (Figs. 39A
for sterilization. Sterilization may be performed because and B).
in multipara patients the lower abdominal wall is lax; ■ ■Incise the fascia until a small amount of preperitoneal
making the fascia thinner and easy elevation by hand is fat is identified. Place stay sutures in the fascial edges.
possible. Bleeding due to accidental damage to a major ■ ■The stay sutures aid with retraction of the abdominal
vessel during this initial stage is one of the most dangerous wall and can be used to secure the port to the fascia,
complications of laparoscopic surgery. preventing its displacement during the surgery.
The Hasson trocar system was initially developed ■ ■A hemostat is stabbed into the peritoneum while
for laparoscopy in patients who have had a previous holding the stays up (Fig. 38).
laparotomy. After seeing benefit of open access technique, ■ ■The give-way of the peritoneum can be felt as
many surgeons started using open access technique peritoneum is perforated and then the hemostat is
routinely in all their patients. An access wound was made opened to widen the opening.
using traditional open techniques and the Hasson trocar ■ ■Open the peritoneum bluntly, sweep the underside
and cannula was designed to both fix the port and seal of the abdominal wall with the index finger to clear
this larger wound round the port. It requires the use of omentum or bowel, and confirm the absence of
sutures to prevent slippage of port. This involved making adhesions in the region of the incision (Figs. 39A
a small entry wound directly through the scar tissue of the and B).
umbilicus and then dilating this up by passage of a blunt, ■ ■Surgeon should insert his finger to feel all around inside
preferable conically tipped trocar and cannula (Figs. 40 the abdominal cavity to feel any possible adhesion.
and 41).

Fig. 35: Disposable Hasson trocar. Fig. 36: Reusable Hasson trocar.