Page 4 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

CHAPTER 6: Abdominal Access Techniques 3

If surgeon is going to perform any upper abdominal
procedures such as cholecystectomy, fundoplication,
duodenal perforation, hiatus hernia, etc., it is good
practice to have nasogastric tube in place. A distended
stomach will not allow proper visualization of Calot’s
triangle and then surgeon has to apply more traction over
fundus or Hartmann’s pouch, and this may cause tenting
of common bile duct (CBD) followed by accidental injury.
In gynecological or lower abdominal minor laparoscopic
procedure, it is not necessary to put nasogastric tube.
In MAS, shaving of skin is not must and if necessary, it
should be done on operation table itself by surgeon.

Operating Room Setup
Fig. 5: Eye of Veress needle. An organized well-equipped operation theater is essential
for successful laparoscopy. The entire surgical team should
be familiar with the instruments and their function. Each
Veress Needle Insertion instrument should be inspected periodically for loose or
The standard method of insufflations of the abdominal broken tips even if the same instrument was used during
cavity is via a Veress needle inserted through a small skin a previous procedure. It is necessary to confirm proper
incision over inferior crease of umbilicus. Disposable and sterilization of instruments because the surgeon ultimately
reusable metal Veress needles are available commercially is responsible for the proper functioning of all instrument
in different lengths (8–20 cm), i.e., long for obese patients, and equipment.
short for thin or pediatric patients. The entire instrument should be placed according to
Before using Veress needle, it should be checked for its wish of the surgeon so that it should be ergonomically
patency and spring action. Spring action of Veress needle perfect for that surgery. The coaxial alignment should
can be checked by pulling the head out. The disposable be maintained. Coaxial alignment means the eye of the
Veress needle spring action can be checked by pressing the surgeon, target of dissection, and monitor should be
sharp end against any sterilized draping. placed in same axis.
Insufflation via the Veress needle creates a cushion
of gas over the bowel for insertion of the first trocar. Patient Position
Insufflation then retracts the anterior abdominal wall, Initially at the time of pneumoperitoneum by Veress
exposing the operative field. needle, patient should be placed supine with 15° head
down. The benefit of this Trendelenburg’s position is that
Preparation of Patient bowel will be pulled up and there will be more room in
The patient should be nil orally since the morning of pelvic cavity for safe entry of Veress needle. It is important
surgery. In some of the procedure such as laparoscopic to remember that patient should be placed in head-down
hysterectomy or colorectal surgery where distended bowel position only if surgeon is planning to insert Veress needle
may interfere, it is good to prepare bowel prior to the night pointing toward pelvis cavity. If surgeon is planning to
of surgery by giving some mild purgative (polyethylene insert Veress needle perpendicular to abdominal wall as
glycol). Bowel preparation can minimize the need of in case of very obese patient, previous midline incision
accessory port to retract the bowel. or diagnostic laparoscopy in local anesthesia, the patient
Before coming to operation theater, patient should should be placed in supine position otherwise all the
always void urine. The full urinary bladder may get bowel will come just below the umbilicus and there is
perforation at the time of insertion of Veress needle or increased risk of bowel injury.
trocar. If the laparoscopic procedure is of short duration In gynecological laparoscopic procedures or if
and is going to be performed of upper abdomen, then laparoscopy is planned to be performed together with
Foley catheterization is not necessary. If gynecological hysteroscopy, patient should be positioned in lithotomy
operative surgery or any major general surgical lower position and one assistant should be positioned between
abdominal procedure has to be performed (such as hernia the leg of patient (Fig. 6). Patient’s leg should be
or adhesiolysis), it is wise to insert Foley catheter.