Abdominal Access Techniques in laparoscopy

Abdominal Access Techniques in laparoscopy

1. Prof Dr. Salma Sultana Professor & Head Dept. of Surgery Dhaka Medical College Hospital Abdominal Access Techniques

2. Introduction In minimal access surgery, the technique of first entry inside the human body with telescope & instruments is called access technique . Synonyms of minimal access surgery: Minimally invasive surgery Minimal access therapy Main objective is the reduction in the trauma of access. Examples: Thoracoscopy Retroperitoneoscopy Axilloscopy 20% of laparoscopic complications happens at the time of initial access.

3. Types of access 2 types of access in laparoscopy: Closed access Open access Closed access : Blind technique. Pneumoperitoneum created by Veress needle. Possible in preformed cavity like abdomen. Not possible in axilloscopy , retroperitoneoscopy or extra-peritoneal approach. Open access : Open technique by direct visualization (mini laparotomy). Pneumoperitoneum is created after inserting blunt trocar inside abdominal cavity under direct vision.

4. Different techniques of open access: Hasson’s method Scandinavian method Fielding method

5. Relevant anatomy for access into abdomen : In midline, umbilicus is site of choice. At this level one have to penetrate only the followings: Skin with minimum fat Linea alba Peritoneum The midline is devoid of muscle fibres , nerves & vessels. At the inferior edge pyramidalis may be found. When midline is not used for access, location lateral to the linea semilunaris is good for access to avoid injury of sup. & inf. epigastric vessels. The colon is attached to the lateral abdominal wall along both gutters. So puncture laterally should be under video control. Anterior abdominal wall anatomy.

6. Preparation of patient Patient should be kept NPO since the morning of surgery. In case of colorectal surgery, bowel preparation is needed . Patient should always void urine before entering OT. Foley’s catheterization is not needed in surgery of upper abdomen, but it is a must in case of lower abdominal procedures. NG tubing is good in case of upper abdominal procedures to deflate the stomach, but not necessary in case of lower abdominal procedures.

7. Operation room set-up Check the instruments. Check sterilization. Co-axial alignment means the eye of surgeon, target of dissection & the monitor should be placed along same axis .

8. Patient position Supine with 10-20 degree head down ( Trendelenburg’s position): Veress needle pointed towards pelvic cavity. Good for lean & thin patients. Supine position: Veress needle inserted perpendicularly to abdominal wall. Good for very obese patients, diagnostic laparoscopy under L/A. Lithotomy position : Gynaecological laparoscopic procedures. Colorectal procedures. Lateral position: Thoracoscopy Retroperitoneoscopy

9. Position of surgical team French p0sition : In surgery of upper abdomen, surgeon stands between the legs of the patient. American position : In surgery of upper abdomen, surgeon stands to the left of the patient. Once all the ports are in position, surgeon should come opposite to the side of pathology to start surgery. In most of upper abdominal surgery, camera assistant should stand left to the surgeon . In lower abdominal surgery, he/she should stand right to the surgeon. Posture of surgeon : Shoulder relaxed. Arms alongside the body. Elbows at 90° angle. Forearm horizontal.

10. Preparation for access All connections to the telescope are attached. Focusing the camera : While focusing, distance between gauge piece & tip of the telescope should be 6-8 cm. White balancing of camera.

11. Choice of gas for Pneumoperitoneum Filtered room air: Advantage: Easily available. Does not alter the internal environment of abdomen. Disadvantage: Increased risk of air embolism. Combustible. CO₂ : Advantage: 200 times more diffusible than oxygen. Less risk of air embolism. Non-combustible. Easily cleared by lungs. Decreases pH of peritoneal fluid, so mild antiseptic effect.

12. Choice of gas for Pneumoperitoneum Disadvantage: Carbonic acid irritates diaphragm causing shoulder tip pain & abdominal discomfort. N₂O: Advantage: Less chance of air embolism. Mild analgesic effect. Disadvantage: More combustible than air. Helium : Inert gas, but no added benefits over CO₂.

13. Umbilicus is good site for access because: Thinnest abdominal wall. Cosmetically better. No significant blood vessels. Ergonomically better (center point of abdomen). Precautions for umbilical port for reducing rate of infection & ventral hernia: Umbilicus should be cleaned meticulously before incision. Rectus sheath of all 10 mm port should be repaired. During tissue retrieval through umbilical port, infected tissue should be put in endobag . It reduces contamination. Maintain proper hemostasis to prevent hematoma formation at port site.

14. Where in the umbilicus ? Superior or inferior crease of umbilicus, for non-obese patients. Trans-umbilical for obese patients or for diagnostic laparoscopy under L/A. Smiling incision over the inferior crease of umbilicus. Stabilization of umbilicus and incision: Stabilized with the help of 2 Ellis forceps. Initial 1 mm incision along the inferior crease with blade no. 11. Incision is just skin deep. Mosquito forceps is introduced to clear the subcutaneous tissue.

15. Abdominal entry Veres needle   Open technique Optic trocar

16. A spring-loaded, inner stylet is positioned within the outer cannula This inner stylet has a dull tip to protect any viscera from injury by the sharp, outer cannula. Direct pressure on the tip—as when penetrating through tissue—pushes the dull stylet into the shaft of the outer cannula When the tip of the needle enters a space such as the peritoneal cavity, the dull, inner stylet springs forward Veres Needle: some facts

17. Introduction of Veress needle Two Allis forceps is applied over crease of umbilicus. 2-mm stab wound over inferior crease of umbilicus.

18. Introduction of Veress needle Veress needle should be held like a dart. During entry, surgeon can hear & feel 2 click sounds, 1 for linea alba, 1 for peritoneum . In other areas of abdominal wall, surgeon will get 3 click sounds, 2 for the rectus sheath, 1 for the peritoneum. Once the click sounds are felt, one should stop pushing the needle further & check various indicators. The lower abdominal wall should be lifted such that Veress needle lies at 90° with the abdominal wall but at 45° with the body of patient pointed to anus.

19. Irrigation test. Aspiration test Needle movement test : once inside the abdominal cavity- tip is free. No resistance on further gentle push. Irrigation test: Injected normal saline will flow freely. Aspiration test: Injected normal saline can’t be sucked – Peritoneal cavity Some fluid – Preperitoneal space More fluid – Acsites , cyst, UB Fresh blood – Vessel injury Fecal matter – Perforation of bowel Hanging drop test Indicators of safe Veress needle insertion:

20. Quadro-manometric indicators of insufflator Preset insufflation pressure Actual pressure Gas flow rate Volume of gas consumed

21. Quadro-manometric indicators of insufflator Preset presure : Ideally should be 12 mm Hg. Should not be more than 18 mm Hg (even in case of obese pt.) In diagnostic laparoscopy under L/A, pressure should be around 8 mm Hg. Actual presure : True intra-abdominal pressure can be determined by switching off the flow from insufflator for a moment. Actual pressure of more than 20-25 mm Hg causes detrimental effects : Venous return - DVT, hidden cardiac ischemia Tidal volume (diaphragmatic compression) Risk of air embolism Risk of surgical emphysema

22. Quadro-manometric indicators of insufflator Flow rate : Should be adjusted to 1 L/min. Veress needle can give away CO₂ flow at maximum 2.5 L/min. When flow is > 7 L/min inside the abdominal cavity through cannula, there is a risk of hypothermia . Total gas used: Normal size human abdomen needs 1.5 L of CO₂ to achieve a pressure of 12 mm Hg. 3 L (rarely 5-6 L) for big size abdomen and for multiparous patients to achieve the same pressure.

23. Primary trocar insertion After creation of pneumoperitoneum , most common causes of injury during insertion of trocars are: Inadequate stabilization of abdominal wall. Excessive resistance to trocar insertion. Excessive, misdirected or uncontrolled force applied by surgeon. Adequate stabilization by – Full insufflation. Complete muscle relaxation. Increase distance between ant. abdominal wall & viscera. Resistance to trocar insertion is overcome by skin incision of adequate length .

24. Primary trocar insertion Steps: Patient position - Supine with head down . Site - Same site of Veress needle entry. Incision Initial 1 mm stab wound converted to 11 mm incision. Smiling in shape. Along the inferior crease of umbilicus. Blunt dissection - of fatty tissue by needle holder or artery forceps. Trocar should be held like a pistol . Angle of insertion - Initially it should be perpendicular to abdominal wall, but once surgeon feel give away sensation , it is tilted to 60°-70 °.

25. Primary trocar insertion 7) Confirmation Audible clicks. Whooshing sound. Loss of resistance felt in trocar. Once the telescope is inside , the site just below the entry of primary port is examined for any vessel or bowel injury. Slipping out of ports occurs, when port wound becomes bigger than the size of the cannula. To prevent this- A simple stitch over skin can be given. Cannula can be fixed with sterile adhesive tapes.

26. Working & subsequent ports Avascular area is located first by transillumination of skin with the telescope tip. Initially direction of entry of trocar is perpendicular. As soon as tip is seen, direction of trocar is changed towards free space to avoid injury. Distance between 2 ports should never be less than 5 cm . Baseball diamond concept.

27. Hasson Trocar Harrith (“Harry”) M Hasson (1931-2012)

28. Open technique An open technique involves creating a mini laparotomy into which a cannula is inserted. Disadvantages of open technique : Persistent uncontrolled CO₂ leakage. Increased incision size. Increased time for placement. Advantages of open technique : Little risk of injury underlying structures, irrespective of experience. Useful in previous abdominal surgery or underlying adhesions. Risk of extra-peritoneal insufflation is eliminated. As fascia is repaired properly, so rate of herniation is decreased. Useful in muscular man & children with strong abdominal wall. Useful for Surgeons or Gynaecologists lacking sufficient upper arm strength to elevate the abdominal wall of pt.

29. Steps of open access technique : A transverse incision over sub-umbilical region. Upper & lower skin flaps are retracted. Subcutaneous tissue is dissected upto the linea alba & rectus sheath. Stay sutures are taken on rectus sheath at both sides of midline, and pulled to elevate the rectus. Hemostat is stabbed into the peritoneum Skin incision for open technique 5) Sheath is incised pointing upwards along the linea alba. Incision should not puncture the peritoneum. 6) A haemostat is stabbed into the peritoneum, holding the stays. The opening of peritoneum is widened by opening the hemostat.

30. Steps of open access technique : Introduction of Hasson trocar. Finger insertion after open access will confirm adhesion 9) Blunt trocar-cannula is inserted through first port after visualization of underlying viscera. Big incision is not necessary, cannula can dilate smaller incisions. 10) A purse string suture can be applied to big incision to hold the port in position. Finger is inserted to feel around inside the abdominal cavity for adhesions. Small adhesions can be broken with finger.

31. Open technique Open Fielding technique: Everted umbilicus is incised from apex to caudal direction. Skin is retracted to expose the cylindrical umbilical tube. The tube is then cut downwards upto its junction with linea alba. Blunt dissection through this plane permits direct entry into the peritoneum.

32. Optical trocar Rapid & safe alternative Allows direct visualization of the abdominal wall layers when traversed

33. Palmer’s technique : Veress needle is inserted through left hypochondrium . This area has rarely any viscero -parietal adhesions. This area is preferable where umbilical entry is contra-indicated. There should not be any hepato -splenomegaly. Diagnostic laparoscopy under L/A: Intra-venous sedation. Gas flow – 0.5 L/min. Pressure – 8 mm Hg. Preferred gas - N₂O. Pneumoperitoneum in special cases:

34. Scarred abdomen : A general rule is to choose the quadrant of the abdomen opposite to that of the scar. Contra-indication of umbilical entry: Previous midline incision. Portal hypertension with recanalyzed umbilical artery with advanced cirrhosis of liver. Umbilical abnormalities i.e. urachal cyst, sinus, hernia etc.

35. Complication of Access Techniques Improper trocar insertion causes most of the operative complications of laparoscopic surgery. The overall incidence of complications is relatively low (about 2%). Visceral injuries: Incidence of injury of Hollow Viscus Small Bowel (2.7%) Large Bowel (0.15%) Bladder (0.5%) Stomach (0.02%) Solid organs Liver Spleen

36. Complication of Access Techniques Vessel injury Inferior epigastric Omental Mesenteric vessels Aorta Inferior vena cava Other complications Gas embolism Pneumo-omentum Surgical emphysema Pneumo -mediastinum Sudden collapse

37. Complication of Access Techniques Mild to moderate hypotension: Discontinue gas insufflation immediately & reduce intra-abdominal pressure to 8 mm Hg. Rule out retro-peritoneal bleeding. If bleeding or expanding hematoma is seen, proceed immediately for laparotomy.

38. Port Closure Techniques All the 10 mm or greater than 10 mm port should be repaired properly to prevent any future possibility of hernia . The rectus sheath is only necessary to suture with vicryl . Only one stitch is required in the middle which will convert 10 mm wound into 5 mm. The 5 mm port wounds are not necessary to repair.

39. Problems due to pneumoperitoneum : Hypothermia Cardiac arrhythmias Cardiovascular collapse Pulmonary insufficiency Gas embolism Venous thrombosis Cerebral edema/ ischaemia Ocular hypertension Extraperitoneal insufflations (Subcutaneous emphysema, Pneumomediastinum )

40. Port Positions

41. Stab Incision Technique 2 cannulas 2 stab incisions

42. Evolution

43. Future Directions Limitations of current MIS technology No wrist − Motions are limited to 3 degrees of freedom − Limits suture techniques 2-dimensional images − Lack of depth perception Distance from operative field − Image is in opposite direction from where surgeon is working

44. Future Directions Solution---daVinci operative system Robot arm with 5 degrees of freedom True 3-dimensional images Work station allows “total immersion”

45. Future Directions Ready for Pediatric MIS? Yes Infant MIS? Not quite Instruments are still 8 mm and scope is 11 mm Robotic arms cumbersome on smallest patients -- infants? Developing new techniques to utilize newer technology as it emerges. Where daVinci helps most--small operative field with little maneuverability

46. The Ever Changing Future A New Endoscopic Microcapsule Robot using Beetle Inspired Microfibrillar Adhesives * * Proceedings of the 2005 IEEE/ASME International Conference on Advanced Intelligent Mechatronics Monterey, California, USA, 24-28 July, 2005

47. The Ever Changing Future Nanobots Operated by Clinician Engineers or Surgeons?

48. QUESTIONS