Chapter 6 Basic Laparoscopic Surgical Skills Kiyokazu Nakajima, Jeffrey W. Milsom, and Bartholomäus Böhm Establishing Pneumoperitoneum Veress Needle Technique Pneumoperitoneum is most often established using a Veress needle. The needle is usually inserted at the site where the primary cannula for the laparoscope will be placed. Our preference is a vertical infra- umbilical incision because it overlies the location where the skin, fascia, and parietal peritoneum converge and fuse. If the patient has had prior abdominal surgery, we generally avoid the old incision scars and enter from a remote site in the upper abdomen. After the skin is incised, the subcutaneous fatty tissue is bluntly dis- sected until the linea alba is visible. The linea alba is grasped using two Kocher clamps and pulled anteriorly. A “U-shaped” 2-0 or 0 fascial suture can be placed around the cannula insertion site at this time to facilitate later fascial closure, and the Veress needle is inserted perpen- dicular to the abdominal wall. Before using the Veress, the surgeon should check that the needle is patent and the spring-loaded safety mechanism is functioning properly. The needle should be held between the thumb and index fi nger not more than 3 cm from the tip to ensure it passes safely and steadily through the fascia (Figure 6.1). Steadying the heel of the needle-wielding hand on the abdominal wall will mini- mize the risk of uncontrolled insertion through the fascia. The needle should be advanced perpendicularly through the fascia for approxi- mately 1 cm; then the needle should be directed toward the pelvis. As the needle’s spring mechanism crosses the posterior rectus sheath and peritoneum, a defi nite give with a click is usually felt. Once inside the peritoneal cavity, the needle tip should feel free and move easily when the hub is moved laterally. Once the needle is in place, its intraperitoneal location is verifi ed with the following checks before gas insuffl ation: 1. A 10-mL syringe fi lled with normal saline is attached to the needle. Three milliliters is injected and then aspirated. No resistance should 66 Chapter 6 Basic Laparoscopic Surgical Skills 67 Figure 6.1. The Veress needle is held between the surgeon’s thumb and index fi nger midway up the shaft. The risk of plunging deeply can be minimized by placing the base of hand on the body wall (asterisk). be felt during injection. The aspirate is examined for return of blood, urine, or bowel contents. 2. The “hanging drop” test is performed, which confi rms that the needle has entered a cavity. The test is done by relaxing all retraction on the abdominal wall, placing a drop of saline on the open hub of the Veress needle, then lifting up the Kocher clamps placed on the abdominal fascia. When the clamps are lifted, the saline will quickly drop into the peritoneal cavity if it has been entered. Although these tests merely indicate whether a cavity has been entered, and may not distinguish between the peritoneal cavity and the preperitoneal space or a hollow viscera, we believe these tests should always be performed before gas insuffl ation. After the syringe test and the drop test, the insuffl ation line is con- nected to the needle and CO2 insuffl ation is started. The intraabdomi- nal pressure is monitored during early gas insuffl ation (Table 6.1). The pressure should be less than 5 mm Hg at the beginning of CO2 insuffl a- tion. If the pressure is greater than 5 mm Hg, the needle can be either in the abdominal wall, preperitoneal space, adjacent to or within an intraabdominal viscus, or buried in the omentum. Elevating the abdom- inal wall and repositioning the needle (usually by simple axial rotation) will almost always result in proper pressure readings. If the pressure remains elevated or increases rapidly over 10 seconds, the needle tip is likely misplaced, and it should be removed immediately and inserted again, or the surgeon should consider an open technique. 68 K. Nakajima et al. Table 6.1. CO2 monitor reading – various scenarios on Veress needle insertion Pressure Flow Abdominal distension Possible etiology Starts low Low at fi rst Distends gradually Normal Rises gradually Starts low Low at fi rst Not much 1) Leak in the system 2) Needle in hollow organs or intravascular Stays low Stays high Starts low Low at fi rst Not much or no Empty CO2 cylinder distension Stays low Then none Starts high Low or none No distension 1) Occlusion in system 2) Needle in abdominal wall, adhesions, or intramural (organ) Stays high Open-Hasson Technique Although some surgeons use the “open-Hasson” technique routinely in all patients, it is still controversial whether this technique minimizes risks of injury to the abdominal viscera at the initial abdominal access.1 However, surgeons should always readily move to the open technique when any diffi culties arise using the Veress needle technique. Cur- rently, we use this technique selectively when dense intraabdominal adhesions are suspected: e.g., cases with history of prior major abdomi- nal surgery. In this technique, the peritoneal cavity is opened and a blunt-tipped open “Hasson” cannula is introduced under direct vision through a mini-laparotomy. The standard open cannula consists of three pieces: a cone-shaped sleeve, a sheath with a trumpet or fl ap valve, and a blunt-tipped obturator. The sleeve can be moved up and down the sheath until it is properly positioned. There are two suture struts on the sleeve or the sheath to affi x the cannula to the fascial and peritoneal incisions. A 2-cm skin incision is made at the selected entry site. A longer inci- sion will result in the major leakage of CO2 gas during the insuffl ation. The subcutaneous tissue is bluntly dissected and the underlying fascia is identifi ed and incised. This incision should be just long enough to admit the surgeon’s index fi nger. The abdominal entry is confi rmed visually and by digital palpation, to ensure the absence of intraabdomi- nal adhesions in the vicinity of the incision. The cannula is then inserted under direct vision between two hemostats that grasp the peritoneum. Two sets of 0 or 2-0 sutures are placed on either side of the fascial inci- sion and wrapped around the struts to fi rmly seat the cannula in the peritoneal cavity (Figure 6.2). Some surgeons place these fascial sutures fi rst, use these to elevate the fascia, and then make the fascial incision. Care should be taken not to deeply open the fascia, because underlying peritoneum and viscera can be damaged in thin patients. The CO2 line Chapter 6 Basic Laparoscopic Surgical Skills 69 is connected to the sidearm port and pneumoperitoneum is established under continuous monitoring of the intraabdominal pressure. Use of Optical Access Trocar The third alternative for the establishment of pneumoperitoneum is the use of so-called optical access trocars. The trocar used in this technique (e.g., Bladeless Trocar; Ethicon Endo-Surgery, Cincinnati, OH) has a clear, tapered (bladeless) optical obturator, which provides visibility of individual tissue layers during insertion when used with an endoscope. A 0° or 30° endoscope connected to the light source and monitor is inserted into the opening at the proximal end of the obturator until it reaches the distal tip of the obturator. The obturator is then introduced through a skin incision and advanced by applying continuous but controlled pressure with a rotating motion. The pene- tration of the obturator tip is endoscopically monitored and the individual tissue planes can be seen as the obturator tip advances (Figure 6.3). The trocar advances by dilating the tissue planes, not by cutting. After laparoscopic verifi cation of the intraperitoneal place- ment, CO2 insuffl ation is started directly through the cannula. This technique is best suited for obese patients with a thick abdominal wall, where a standard “open” technique via mini-laparotomy is occasion- ally technically diffi cult. Figure 6.2. The Hasson cannula is introduced into the body wall using two fascial sutures which elevate the anterior rectus fascia. Later, these are used to secure the cannula and also to close the fascia at the conclusion of surgery. 70 K. Nakajima et al. A Figure 6.3. Optical access trocar is inserted into the abdominal wall. A The laparoscope is placed into the obturator while twisting the sheath, all under laparoscopic guidance. B A cross-sectional image of the body wall is obtained while using B the optical access trocar. Chapter 6 Basic Laparoscopic Surgical Skills 71 Trocar Insertion and Stabilization Trocar Insertion In general, we place four to fi ve cannulae for most colorectal proce- dures: one for the laparoscopic camera, two for the operating surgeon, and one or two for the assistant surgeon. This technique provides best surgical fl exibility in all four quadrants, allowing operating and assis- tant surgeons to cooperate. In most instances, the operating surgeon will place the cannula opposite to the site of the pathology, which allows the greatest room to work and to visualize the pathology site. Because any abdominal wall cannula will restrict the mobility of the laparoscopic instruments, the cannula locations should also be chosen to allow the greatest mobility possible, given several additional considerations: each cannula should be placed with a distance of at least 8 cm to prevent the instruments from “sword-fi ghting” each other. In addition, cannulae should also be placed 6–8 cm away from the lapa- roscope site because closer placement impedes a clear overview of the laparoscope. After pneumoperitoneum is established with the Veress needle, the umbilical incision is usually used for the fi rst cannula insertion.