Various Abdominal Entry Techniques in Laparoscopic Surgery Comprehensive Lecture by Dr. R.K. Mishra скачать в хорошем качестве

Various Abdominal Entry Techniques in Laparoscopic Surgery Comprehensive Lecture by Dr. R.K. Mishra

Demonstration of Technique for Various Abdominal Entry Techniques in Laparoscopic Surgery Laparoscopic surgery has revolutionized the field of minimally invasive procedures, offering patients quicker recovery times, reduced pain, and minimal scarring. One of the critical initial steps in any laparoscopic surgery is establishing access to the abdominal cavity, also known as pneumoperitoneum. Proper abdominal entry is essential for safe and successful laparoscopic outcomes, and various techniques have been developed to cater to different surgical needs and patient factors. Here’s an in-depth look at the key techniques used in laparoscopic abdominal entry. 1. Veress Needle Technique The Veress needle technique is one of the most commonly used methods for establishing pneumoperitoneum in laparoscopic surgery. It is considered a closed technique, where the needle is introduced into the abdomen before insufflation. Indications: Suitable for patients without extensive abdominal scarring or previous abdominal surgeries. Technique: A small incision is made at the selected entry point, usually the umbilicus or supraumbilical region. The Veress needle is inserted at a 45-degree angle toward the pelvis, ensuring a smooth, quick entry through the fascia and peritoneum. The needle's proper placement is confirmed by performing the "double-click" test or "hanging drop" test. Carbon dioxide is then insufflated until the desired intra-abdominal pressure (typically 12-15 mmHg) is reached. Advantages: Fast, minimal tissue trauma, and associated with fewer complications. Limitations: Risk of vascular or visceral injury in patients with previous surgeries or altered anatomy. 2. Open (Hasson) Technique The open technique, developed by Hasson, provides direct visualization of the abdominal wall layers as they are incised, reducing the risk of blind entry injuries. This technique is particularly useful in patients with previous abdominal surgeries, where adhesions might be present. Advantages: Reduced risk of injury to abdominal organs, improved visualization, and control during entry. Limitations: Takes more time and requires meticulous suturing, with potential for gas leaks. 3. Direct Trocar Insertion (DTI) Direct trocar insertion is a relatively newer technique that avoids the use of a Veress needle, allowing for immediate trocar insertion to establish pneumoperitoneum. Indications: Ideal for experienced surgeons with a thorough understanding of abdominal anatomy and in patients with lower risk of adhesions. Technique: A small skin incision is made at the entry point. A trocar is directly inserted through the abdominal wall layers until it enters the peritoneal cavity. CO₂ insufflation is initiated once the trocar is confirmed to be intraperitoneal. 4. Optical Trocar Entry The optical trocar technique allows the surgeon to visualize each layer of the abdominal wall as the trocar is advanced, improving safety and reducing the likelihood of injury. Indications: Suitable for all patients, including those with potential adhesions. Technique: After a small incision, an optical trocar with a camera is introduced into the abdominal cavity. As the trocar advances, the surgeon views each layer on a monitor, allowing controlled entry. Once inside the peritoneal cavity, CO₂ insufflation is initiated. Advantages: Provides real-time visualization, minimizing the risk of injury. Limitations: Requires specific equipment and may take longer than traditional closed techniques. 5. Trans-Umbilical and Supraumbilical Entry For specific surgeries, such as Total Laparoscopic Hysterectomy (TLH) or in cases where pelvic access is paramount, a supraumbilical or trans-umbilical entry can be beneficial. Indications: Often used for gynecologic surgeries or patients with lower abdominal adhesions. Technique: A small incision is made above or within the umbilicus. The Veress needle or optical trocar is inserted following the previously discussed protocols. 6. Palmer’s Point Entry Palmer’s point, located in the left subcostal region, provides an alternative entry site, particularly valuable for patients with previous abdominal surgeries or those with a known high risk of adhesions. Indications: Patients with obesity, previous abdominal surgeries, and in cases where umbilical entry may be contraindicated. Technique: The Veress needle or optical trocar is introduced at Palmer’s point, 2 cm below the left costal margin in the midclavicular line. Advantages: Low risk of adhesions at this site, with a reduced risk of injury to major vessels or bowel. Limitations: Limited space and visibility in obese patients; requires caution around the spleen. World Laparoscopy Hospital Cyber City, Gurugram NCR Delhi, India World Laparoscopy Training Institute Bld.No: 27, DHCC, Dubai, UAE World Laparoscopy Training Institute 5401 S Kirkman Rd Suite 340 Orlando, FL 32819, USA