Page 18 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

CHAPTER 6: Abdominal Access Techniques 17

Insufflation through unscarred such as subcostal region, or technique is particular useful in cases where umbilical
if this is scarred, the iliac fossa is better. A general guideline entry is contraindicated, it is preferred to use left upper
is to choose the quadrant of the abdomen opposite to that quadrate for entry of Veress needle. The Veress needle is
of the scar. introduced through left hypochondria, i.e., Palmer’s point
2 cm below the left subcostal margin in midclavicular line
Contraindications of Umbilical Entry (Fig. 46). Special care should be taken that there should
■ ■Previous midline incision not be hepatosplenomegaly. After access though Palmer’s
■ ■Portal hypertension with recanalized umbilical artery point, umbilicus site is rechecked for any adhesion or
with advanced cirrhosis of the liver other abnormalities. If necessary, umbilicus port may be
■ ■Umbilical abnormalities viz. urachal cyst, sinus, hernia. introduced under vision.

PNEUMOPERITONEUM IN SPECIAL Mishra’s Technique
CONDITIONS This access technique we have developed where little
Palmer’s Technique modification of Palmer’s technique is done. We give
incision 2 cm above the costal margin in midclavicular
This access was advocated by Palmer in the 1940s because line called Mishra’s point (Fig. 47). To introduce Veress
visceral parietal adhesions are rarely encountered in needle at Mishra’s point abdominal wall is stretched down
this area (Fig. 44). A small incision is made to allow the and brought below the costal margin. Advantage of this
insertion of the Veress needle through left subcostal technique is there is no incidence of hernia because after
margin (Fig. 45). In addition, some authors feel that surgery incision retract back to 2 cm above the costal
because the abdominal wall in the area is supported by margin (Fig. 48). During insertion of Veress needle or
the rigid thoracic wall, insertion of the needle is more trocar through the palmer’s point, the tip of the trocar
controlled than in the periumbilical area. Palmer’s should be pointed toward the stomach to prevent injury of

Fig. 44: Palmer’s point of access.
Fig. 45: Palmer’s point 2 cm below the costal margin.

Fig. 46: Veress Needle insertion through Palmer’s point. Fig. 47: Mishra’s point 2 cm above the costal margin.