Page 8 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

CHAPTER 6: Abdominal Access Techniques 7

Fig. 15: Veress needle should be pointed toward anus but Fig. 16: Irrigation test.
perpendicular to abdominal wall.

gently move the tip of needle there should not be feel of
any resistance. It is very important to remember that
Veress needle should not be moved inside the abdominal
cavity much, otherwise there is a risk of laceration of bowel
to be punctured.

Irrigation Test

A 10-mL syringe should be taken in one hand and
surgeon should try to inject at least 5 mL of normal saline
through Veress needle. If tip of Veress needle is inside the
abdominal cavity, there will be free flow of saline otherwise
some resistance is felt in injecting saline (Fig. 16). Fig. 17: Aspiration test.

Aspiration Test
abdomen, there is negative pressure. If tip of the Veress
After injecting saline, surgeon should try to aspirate that
saline back through Veress needle (Fig. 17). If the tip of needle is anywhere else, the hanging drop test will be
Veress needle is in abdominal cavity, the irrigated water negative (Figs. 18A and B). Once it is confirmed that
cannot be sucked. But if it is in preperitoneal space or in Veress needle is inside the abdominal cavity, the tubing of
muscle fiber or above; the rectus the injected water can insufflator is attached and flow is started.
be aspirated back. In aspiration test, if more irrigated fluid
is coming, then surgeon should suspect ascites, some Measurement of Intra-abdominal Pressure
cysts or perforation of urinary bladder. If fecal matter is Measure intra-abdominal pressure by attaching the Veress
seen then perforation of bowel may be the reason and needle to the laparoscopic insufflator. An intra-abdominal
if blood is coming then the vessel injury is the cause. If position of the needle is suggested for intra-abdominal
any fresh blood or fecal fluid is aspirated in the syringe, pressure ≤ 10 mm Hg. In one large observational study,
surgeon should not remove the Veress needle and urgent confirmation of low intraperitoneal pressure was the most
laparotomy is required. Leaving Veress needle in position reliable method to confirm Veress needle placement.
is helpful in two ways. First, it is easy to find the punctured Once an intra-abdominal position of the needle is
area after laparotomy and secondly, the further bleeding verified, initiate gas insufflation (typically CO ). A properly
2
will be less. placed Veress needle will allow free flow of gas. Tympany
should be appreciated with percussion of the abdomen in
Hanging Drop Test the right upper quadrant.
For many years, surgeons have been using towel clip
Few drops of saline should be poured over the Veress
needle and abdominal wall should be lifted slightly, if tip to elevate the abdominal wall. This towel clip technique
of the Veress needle is inside the abdominal cavity the of lifting abdominal wall was advocated by Johns Hopkins
hanging drop should be sucked inside because inside the University but after some time it was realized that towel