Page 9 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

8 SECTION 1: Essentials of Laparoscopy

clip technique increases the distance of skin from rest Insufflation of Gas Test, Quadromanometric Test
of the abdominal wall more than distance of abdominal Tubing of the insufflator should be tightly attached with
wall from viscera. Abdominal wall should be held full the help of Luer lock of Veress needle (Figs. 19 and 20).
thickness with the help of thenar, hypothenar and all the For safe access, surgeon should always see carefully all
four fingers (Fig. 15). It is lifted in such a way that angle the four indicators of insufflator at the time of creation
between Veress needles to abdominal wall should be 90° of pneumoperitoneum. If the gas is flowing inside the
and angle between Veress needle and patient should be abdominal cavity, there should be proportionate rise in
45°. At the time of entry of Veress needle, surgeon can hear actual pressure with total gas used. Suppose only with the
and feel two click sounds. The first click sound is due to entry of 200–300 mL of gas, if actual pressure is equal to
rectus sheath and second click sound is due to puncture preset pressure of 12 mm Hg, that means gas is not going
of peritoneum. Anterior and posterior rectus forms one in free abdominal cavity, it may be in preperitoneal space
sheath at the level of umbilicus, so there will be only one or inside omentum or may be in bowel. If gas is flown
click for rectus. >5 L without any distention of abdomen that may be due to
If any other area of abdominal wall is selected for leakage or gas may be going inside the vessel.
access surgeon will get three click sounds. Once these two
click sound is felt, surgeon should stop pushing Veress Quadromanometric Indicators of
needle further inside and he should use various indicators Insufflator (Figs. 21A and B)
to know how far he has accessed. Once the desire length
of Veress needle is introduced in abdomen, the tubing of Quadromanometric indicators are the four important
insufflator should be attached to Veress needle (Fig. 16). It readings of insufflator the insufflator is used to monitor:
is important to keep nice hold on Veress needle throughout 1. Preset insufflation pressure
while gas is flowing; otherwise Veress needle can slip out 2. Actual pressure
and may create preperitoneal insufflation (Fig. 17).

A B
Figs. 18A and B: Hanging drop test.

Fig. 19: Attaching gas tubing with careful hold of Veress needle and Fig. 20: Beginning of insufflation with careful hold over
counter twist over Luer lock of insufflator tubing. Veress needle.