Anatomy for the laparoscopic surgeon Laparoscopic surgery is a safe and effective option for many patients, provided the surgeon knows the relevant anatomic landmarks and variations created by obesity, prior surgery, and aberrant anatomy. Here’s a primer on minimizing patient morbidity and optimizing outcomes. Emad Mikhail, MD, Lauren Scott, MD, and Stuart Hart, MD, MS CASE Obese patient requests total laparo- enlarged uterus of approximately 14 weeks’ scopic hysterectomy size with minimal descensus. An earlier trial A 45-year-old woman (G2P2), who delivered of hormone therapy failed to provide relief. both children by cesarean section, schedules After you counsel her extensively about her an office visit for a complaint of abnormal treatment options, she elects to undergo uterine bleeding. She is obese, with a body total laparoscopic hysterectomy. mass index (BMI) of 35 kg/m2, and has an What anatomy would you review to help ensure the procedure’s success? IN THIS ARTICLE Dr. Mikhail is Assistant Professor, Department of Obstetrics and lthough the vaginal route is preferred Surface anatomy Gynecology, University of South for hysterectomy, total laparoscopic of anterior Florida Morsani College of hysterectomy is another minimally Medicine (MCM), Tampa, Florida. A abdominal wall invasive option that offers lower morbidity page 50 and a shorter hospital stay than the abdomi- nal approach.1 Perhaps more than any other Dr. Scott is Fellow, Division of Vascular anatomy variable, the key to safe, efficient, and effec- Female Pelvic Medicine and of anterior Reconstructive Surgery, Department tive laparoscopic surgery is a comprehensive of Obstetrics and Gynecology, abdominal wall University of South Florida MCM. knowledge of anatomy. For example, a thor- ough understanding of the anatomy of the page 54 anterior abdominal wall is critical to laparo- scopic entry.2,3 Also, pelvic anatomy visual- Veress needle Dr. Hart is Associate Professor, Female Pelvic Medicine and ized two-dimensionally under magnification placement in Reconstructive Surgery, Director during traditional laparoscopy can look very obese women of the Tampa Bay Research and Innovation Center (TBRIC), different than it does during conventional page 55 and Director of the Center for surgery, due to the effects of the pneumo- the Advancement of Minimally peritoneum, steep Trendelenburg position, Invasive Pelvic Surgery (CAMPS) 3 at the Center for Advanced Medical Learning and and/or the use of uterine manipulators. Simulation (CAMLS), University of South Florida MCM. The abdominal cavity is traditionally divided into nine regions. Regardless of the Dr. Mikhail and Dr. Scott report no financial relationships relevant to this article. Dr. Hart reports quadrants chosen for laparoscopic access, being a speaker and consultant for Covidien, thorough knowledge of the relevant surface Boston Scientific, and Stryker and receiving research funding from Cooper Surgical. anatomy increases patient safety during sur- gery (FIGURE 1, page 50). CONTINUED ON PAGE 50 obgmanagement.com Vol. 26 No. 4 | April 2014 | OBG Management 49 anatomy for the laparoscopic surgeon CONTINUED FROM PAGE 49 FIGURE 1 Surface anatomy of the anterior indicates correct placement of the Veress 7,8 abdominal wall needle. Vilos and colleagues demonstrated that Veress intraperitoneal pressure correlates positively with a woman’s weight and BMI Lateral sternal line and correlates negatively with her parity.8 Parasternal line Mammary line Hasson or open technique During the Hasson or open technique, many surgeons use the umbilical ring to gain en- try into the abdominal cavity.9 Many view the umbilical ring as a window into the an- terior abdominal wall, through which access to the peritoneal cavity can be achieved, but Hypo- Hypo- 10 chondriae chondriae it can also be a site of hernia development. Epig astric The shape of the umbilical ring can vary, Transpyloric plane appearing round or oval, but it also can be Lumbar Umbi lical Lumbar obliterated, slitted, or covered completely by a connecting band, which can result in more Transtubercular plane difficult laparoscopic entry.10 Iliac Hypogastric Iliac Palmer’s point In the 1940s, the French gynecologist Raoul Left lateral line Palmer advocated placing the laparoscope at a point in the left midclavicular line, approxi- mately 3 cm caudal to the costal margin, be- The surface anatomy of the anterior abdominal wall is traditionally divided into nine regions. cause visceral-parietal adhesions rarely were found there. Gynecologists still favor this en- try site when intra-abdominal adhesions are Primary port placement likely, especially in patients with a history of Primary port placement, including insertion significant adhesions or multiple previous of the Veress needle, accounts for approxi- pelvic surgeries.11 In a study published by mately 40% of laparoscopic complications.4 Agarwala and colleagues, which included To help minimize complications, surgeons 504 patients with intra-abdominal adhe- should ensure that the operating table re- sions, left upper quadrant entry was found mains level during placement. As the patient to be safe with a complication rate as low as is moved into the Trendelenburg position, 0.39%.12 the great vessels are more in line with the If supraumbilical or left upper quadrant 45-degree angle that most surgeons use port sites are used, the surface anatomy of when placing their Veress needle and pri- the spleen and stomach become relevant. mary trocar, which can lead to an increased The portion of the stomach that is in con- risk of injury. Thus, proper positioning in re- tact with the abdominal wall is represented lationship to anatomy is critical to successful roughly by a triangular area extending be- laparoscopic surgery. tween the tip of the 10th left costal cartilage, the tip of the ninth right cartilage, and the Veress or closed technique end of the eighth left costal cartilage.13 The Most gynecologists employ the closed meth- size and shape of the stomach differs by od or Veress needle approach to establish position. Some authors recommend empty- pneumoperitoneum.5,6 An initial intraperi- ing the stomach using a nasogastric or oral toneal pressure below 10 mm Hg, regardless gastric tube prior to port insertion to avoid 12 of a woman’s body habitus, height, or age, injury. ILLUSTRATION: SHUTTERSTOCK CONTINUED ON PAGE 52 50 OBG Management | April 2014 | Vol. 26 No. 4 obgmanagement.com anatomy for the laparoscopic surgeon CONTINUED FROM PAGE 50 The spleen can be mapped using the decreases. The average distance from the 10th rib as representing its long axis; verti- midline at the pubis is approximately cally, the spleen is situated between the up- 7.5 cm. At the umbilicus, it is approximately per border of the ninth and lower border of 4.6 cm.16,17 The most efficient way to iden- the 11th ribs.13 In patients without splenic tify laparoscopically the inferior epigastric enlargement, the spleen should not be found vessel is to first identify the round ligament. below the rib cage. This can be done using a uterine manipula- tor to deviate the uterus to the contralateral CASE Continued side. Then observe the course of the inferior On the day of surgery, your patient is brought epigastric vessel just medial to the entry of to the operating room. You use the Veress the round ligament into the inguinal canal. needle for insufflation. Your opening pres- The laparoscopic surgeon can then follow sure is 5 mm Hg. You know that an opening the course of the inferior epigastric vessels pressure of less than 10 mm Hg indicates to determine the safest location for place- proper placement, so you continue on to ment of secondary ports. Transillumination place a 10-mm port. After inserting the pri- can identify the superficial epigastric vessels, mary umbilical port through the umbilicus, which course within the subcutaneous tis- you decide to insert secondary ports through sue of the anterior abdominal wall, although lower quadrants. Upon insertion, you note it doesn’t identify the deep inferior epigas- active bleeding at one of the secondary port tric vessels that are beneath the lateral third sites. of the rectus muscle. The superficial epigas- How do you proceed? tric vessels follow a course similar to that of the deep inferior epigastric vessels, however, and can serve as a surrogate to guide safe Vascular anatomy of the placement of accessory ports.17 anterior abdominal wall Landmarks of the anterior abdominal Epigastric vessels Understanding anterior abdominal wall wall during laparoscopic visualization can are the most anatomy and the course of the deep infe- also guide placement of secondary ports. commonly injured rior and superficial epigastric vessels is es- The median umbilical fold, which is the peri- vessels during sential to the safe placement of secondary toneal covering of the umbilical ligament/ laparoscopic surgery laparoscopic ports. Epigastric vessels are urachus, travels between the bladder and the most commonly injured vessels dur- umbilicus in the midline anterior abdominal ing laparoscopic surgery.14,15 The inferior wall. Immediately lateral is the medial um- epigastric vessels originate at the external bilical fold, which is the peritoneal covering iliac, immediately above the inguinal liga- of the obliterated umbilical artery, a branch ment. They course medially to the round of the superior vesical artery that comes off ligament and travel beneath the lateral third the anterior trunk of the internal iliac artery.2 of the rectus abdominis muscle. Using ante- The lateral umbilical folds are lateral to the rior abdominal wall landmarks, the inferior medial umbilical fold and are the peritoneal epigastric artery can be identified midway covering of the deep inferior epigastric ves- between the anterior superior iliac spine sels. Identification of these anterior abdomi- and the pubic symphysis as it travels toward nal wall landmarks can assist the surgeon in the umbilicus. The inferior epigastric artery placing lateral ports so as to avoid injury to also serves as the lateral boundary of Hes- these vessels.