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Entry Techniques in Gynecologic Laparoscopy—A Review

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Entry Techniques in Gynecologic Laparoscopy—A Review Gynecol Surg (2012) 9:139–146 DOI 10.1007/s10397-011-0710-8 REVIEW ARTICLE Entry techniques in gynecologic laparoscopy—a review Johannes Ott & Agnes Jaeger-Lansky & Gunda Poschalko & Regina Promberger & Eleen Rothschedl & René Wenzl Received: 9 June 2011 /Accepted: 19 October 2011 /Published online: 13 November 2011 # Springer-Verlag 2011 Abstract Laparoscopy is one of the most common surgical underpowered in order to assess the risk for rare but life- procedures in gynecologic medicine. Major complications threatening complications. In conclusion, there is no solid associated with gynecologic laparoscopy are relatively rare, evidence proving the superiority of any method of with up to 50% related to laparoscopic entry. Several entry laparoscopic entry. techniques have been developed, all of which aim to provide a safe and easy entry to the abdominal cavity. In Keywords Laparoscopy. Entry techniques . Gynecology. this article, we aim to review the available evidence on Complications . Veress needle . Hasson technique . Direct laparoscopic entry techniques in gynecologic surgery. We trocar entry found no evidence that the Hasson (open) technique is superior to the Veress needle entry, the preferred method of most gynecologists all over the world. When entering the Background abdomen using the Veress needle, an intraperitoneal pressure <10 mmHg is a reliable predictor of correct Laparoscopy is one of the most common surgical intraperitoneal placement. Entry at Palmer’s point (left procedures in gynecologic medicine and has become upper quadrant laparoscopy) is recommended for patients the method of choice over the last few decades for with suspected or known periumbilical adhesions, or a treating benign diseases that require surgery [1, 2]. history or presence of umbilical hernia, or after three failed Major complications from gynecologic laparoscopy are insufflation attempts at the umbilicus. Recently published relatively rare, occurring in three to six per 1,000 cases. trials suggest that direct trocar entry, especially when using However, complications related to access represent one optical trocar systems, might be superior to both the Hasson third to one half of these adverse events [1, 3]. These open technique and the Veress needle entry to avoid complications include serious and potentially life- extraperitoneal insufflation and failed entry. Moreover, threatening adverse events in about 0.4 of 1,000 laparo- blood loss can be reduced and the mean entry time scopic procedures, such as perforation of the bowel, major shortened. Laparoscopic entry techniques are still a contro- abdominal vessels, and vessels of the anterior abdominal versial topic in gynecologic surgery. Many studies are wall. These factors make the access phase the most critical step of a laparoscopic procedure. Less serious complica- : : : : J. Ott A. Jaeger-Lansky G. Poschalko E. Rothschedl tions include postoperative infection, extraperitoneal R. Wenzl (*) insufflations, and subcutaneous emphysema [4]. Department of Gynecology and Obstetrics, In a large survey of 506 patients with entry access injuries, Medical University of Vienna, Waehringer Guertel 18-20, gynecologic procedures accounted for 63% of claims outside 1090 Vienna, Austria the USA and for at least 47% of all cases. The structures injured e-mail: [email protected] most frequently during primary entry access were the small bowel, the iliac artery, and the colon, together accounting for R. Promberger Department of Surgery, Medical University of Vienna, more than 50% of injuries [5].Thesedatapresentamore Vienna, Austria severe spectrum of injuries than those described in procedure- 140 Gynecol Surg (2012) 9:139–146 based studies and underline the severity and possible lethality In very thin patients, especially in those with an android of entry access injuries. pelvis or a prominent sacral promontory, the great vessels Several entry techniques exist [6–8]. However, there is have been reported to lie about 1 to 2 cm underneath the no clear consensus on the optimal method of entry to the umbilicus [13, 14]. In obese patients, the umbilicus is shifted peritoneal cavity [8, 9]. Even a recent Cochrane database caudally toward the aortic bifurcation [15]. These patients systematic review showed no evidence of benefit with are believed to be at an increased risk for major vessel injury regard to the safety of one technique over another [9]. We during the course of a closed laparoscopic entry [16]. aimed to review the available evidence on laparoscopic entry techniques. The Veress needle Basic data on various entry techniques are provided in Methods Table 1. The Veress needle technique is the preferred method of most gynecologists all over the world [17, 18]. A computerized search of the medical literature was The Veress needle is used to establish a pneumoperitoneum conducted with the MedLine database. Articles published by blind insertion into the abdomen, which is then followed up until February 2011 were searched for the keywords by trocar insertion. The classic insertion site in gynecologic laparoscopy, laparoscopic entry, Veress needle, Hasson laparoscopy is in the umbilical area in the midsagittal plane, technique, open trocar entry, complications, and adverse used by 98% of gynecologists [9]. events. The selected articles’ bibliographies were also manually examined for any articles not captured by the Alternative Veress needle insertion sites computerized search. Case reports, abstracts, and letters were excluded. Randomized, quasi-randomized, and non- Alternative sites for Veress needle insertion have been randomized, or cohort, studies on human patients were reported: Insertion in the left upper quadrant (LUQ, included if they compared access methods and provided Palmer’s point) has been mentioned to be useful in obese relevant information on safety and efficacy outcome that and very thin patients, as well as in those with a history of had to be defined a priori. previous open abdominal surgery. In the presence of a large uterine or pelvic mass, it may be also advantageous [19]. The Veress needle is inserted 3 cm below the left subcostal Findings border in the midclavicular line [20]. The method should not be applied in patients with previous splenic or gastric Challenges during laparoscopic entry surgery, portal hypertension, hepatosplenomegaly, and gastropancreatic masses [21]. Laparoscopic entry using Adhesions at the umbilical area are a major concern with Palmer’s point has been reported to be safe and effective, regard to the safety of laparoscopic entry. Rates of up to with a low failure rate of about 1.5%. Complications, 21% and 28% have been reported for women with previous mainly puncture of the left lobe of the liver, have been laparoscopy and previous laparotomy, respectively [10, 11]. found in about 1% of cases [19, 22, 23]. Patients with prior midline incisions, in particular, are at Insertion of the Veress needle directly through the ninth or high risk (up to 42%) [12]. Entry techniques other than the tenth intercostal space, at the anterior axillary line along the classic CO2 insufflation using a subumbilical Veress needle superior surface of the lower rib, has also been reported to be might be useful in these patients. safe. A retrospective analysis of more than 900 cases of Table 1 Overview of different entry techniques Entry technique First published in Rates of major Rates of major visceral injury (%) vascular injury (%) Veress needle entry Gastroenterologia, 1961 [89] 0.04–0.08 0.02–0.07 (classic) Optical Veress needle Endosc Surg Allied Technol, 1.1 Uncertain (minilaparoscopy) 1995 [45] Pressure sensor-equipped J Am Assoc Gynecol Laparosc, Uncertain Uncertain Veress needle 1994 [47] Hasson technique Am J Obstet Gynecol, 1971 [64] 0.05–0.1 0–0.005 (open entry) Direct trocar entry Obstet Gynecol, 1983 [90]0 0 Gynecol Surg (2012) 9:139–146 141 pneumoperitonization through the ninth intercostal space The optical Veress needle revealed only two major complications directly related to the laparoscopic entry [24]. The same indications apply to this Entry using the optical Veress needle is also called method as to the entry at the Palmer’s point [11]. “minilaparoscopy.” A modified Veress needle of 2.1 mm Last but not the least, one might insufflate CO2 through diameter and a 10.5-cm-long cannula are used, allowing the posterior vaginal fornix (“trans cul-de-sac insufflation”) insertion of a thin, zero-degree, semirigid, fiberoptic or transvaginally through the fundus of the uterus. Both minilaparoscope. During insertion of the Veress cannula methods are indicated in extremely obese women [25–32]. with the telescope, one observes a cascade of color For the transuterine route, there was a lower ratio between sequences on the monitor that represent the different punctures and establishment of a pneumoperitoneum, when abdominal wall layers. No randomized trials have been prospectively compared to the classical intraumbilical published as yet. Therefore, the relative risks of this approach in obese women with a BMI >25 kg/m2 [30]. procedure remain unclear [44]. However, in a prospective study of 184 cases, two bowel perforations occurred Additional considerations with the Veress needle entry (Table 1)[45]. As another modification of the classical Veress needle, a The following tests that attempt to determine the correct pressure sensor-equipped Veress needle has been described intra-abdominal placement of the Veress needle have [46]. However, no further studies evaluating
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