Page 6 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

CHAPTER 6: Abdominal Access Techniques 5

are now preferred gas because of increased risk of air
embolism with room air. CO is used for insufflation as
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it is 200 times more diffusible than oxygen and 20 times
more absorbable than room air. It is rapidly cleared from
the body by the lungs and will not support combustion.
N O is only 68% as rapidly absorbed in blood as CO . N O
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has one advantage over CO that it has mild analgesic
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effect, and hence no pain if diagnostic laparoscopy is
performed under local anesthesia. CO has the advantage
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of being noncombustible and allows the concomitant
use of electrocoagulation and laser irradiation. For short
operative procedures such as sterilization or drilling,
under local anesthetic N O may also be used. During
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prolonged laparoscopic procedure, N O should not be a
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Fig. 9: Surgeons stands left to the patient in most of the preferred gas for pneumoperitoneum because it supports
right-sided pathology. combustion better than air. CO when comes in contact
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with peritoneal fluid converts into carbonic acid. Carbonic
In most of the upper abdominal surgery, camera acid irritates diaphragm causing shoulder tip pain and
assistant should stand left to the surgeon and in lower discomfort in abdomen. Carbonic acid has one advantage
abdominal surgery, he or she should stand right to the also that it alters pH of peritoneal fluid (acidotic changes)
surgeon. Camera assistant while holding telescope can and it is mild antiseptic, so the chances of infection may be
pass his or her hand between body and arm of surgeon so slightly less compared to any other gas. Helium gas being
that sometime surgeon can help him to focus his camera inert in nature is also tried in many centers, but it does not
correctly. Camera assistant can be placed opposite to the have any added benefit over CO . Helium may be a suitable
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surgeon to stand but in this case, it is better to have two alternative to CO for creating pneumoperitoneum in
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monitors on both the side of patient, one for surgeon and patients with severe cardiorespiratory disease. Some of the
one for camera stand and other members of surgical team. study suggest that pneumoperitoneum with helium will
The surgeon should work in the most comfortable and not be associated with profound circulatory depression
less tiring position possible with shoulder relaxed, arms or oxygen transport abnormalities. In addition, the use
alongside of the body, elbows at 90° angle and forearm of helium is not associated with acid-base disturbances,
horizontal. although central venous filling pressures are similarly
increased as with the use of CO pneumoperitoneum.
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Preparation for Access However, helium is expensive gas and because of its low
water solubility helium has a lower safety margin than CO
Before starting access, abdomen should be examined for in the event of gas embolism. 2
any palpable lump. It is wise to tell the patient to void
urine before coming to operating room but if the bladder Introduction of Veress Needle
is found full at the time of palpation. Foley catheter and
nasogastric tube should be applied once patient is To access the abdomen with a closed approach using a
anesthetized. Remember that full bladder or distended Veress needle:
stomach may be injured very easily by Veress needle or ■ ■Apply two Allis forceps to evert the inferior crease of
trocar (Figs. 10A to D). umbilicus (Fig. 11).
Once the patient is cleaned painted and draped, all ■ ■Give a 2-mm smiling incision in the skin and the
the connection should be attached, followed by focusing subcutaneous tissue over inferior crease of umbilicus
and white balancing of camera. At the time of focusing, the (Fig. 12).
distance between the gauge piece and tip of the telescope ■ ■Hold shaft of the Veress needle as a dart (Fig. 13).
should be 6–8 cm. ■ ■Guard the length of Veress needle needed to reach the
peritoneal cavity (Fig. 14).
Choice of Gas for Pneumoperitoneum ■ ■Place the needle through the incision to the level of the
fascia (Fig. 15).
At first, pneumoperitoneum was created by filtered ■ ■Grasp and elevate the abdominal wall with your left
room air. Carbon dioxide (CO ) and nitrous oxide (N O) hand. It is important to note that grasping only the skin
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