Pioneering Techniques in Laparoscopic Surgery: Lessons from the Operating Room – ARC Summit
Insufflation failures are critically important in laparoscopy, especially among obese patients who have significant abdominal fat and patients with abdominal scars, as they may have extensive adhesions. Occasionally, initial attempts at insufflation are unsuccessful, leading to high pressures or failed entry, necessitating re-entry which complicates the procedure.
Several techniques are available for gaining abdominal access during laparoscopy. The most common is via the umbilicus, typically using a needle at a 40-45 degree angle. However, it is crucial never to place a patient in the Trendelenburg position during needle insertion, as this increases the risk of vascular injury. I learned this the hard way during my first encounter with an aortic injury.
Another method is the direct entry technique, which, despite appearing barbaric, is quite safe. This technique involves lifting the abdominal wall and inserting the trocar parallel to the major blood vessels. Visual trocars are another option, though no technique is 100% safe.
The Hassan technique involves making a small incision and mimicking a mini-laparotomy, which can be challenging with obese patients due to the thick layer of fat. Uterine insufflation is an alternative method taught by my mentor, M. Wolf. This technique involves inserting a Veress needle through the cervix and fundus of the uterus. Though you cannot perform chromotubation afterwards, it provides another route for abdominal access.
In 1994, Joe Childers reintroduced the Palmer’s technique through the left upper quadrant, known as the Palmer Point, which has become a preferred method, especially for patients with significant obesity. This approach is particularly useful in Louisville, given the high prevalence of obesity.
In cases with extensive prior surgeries, like a patient with 20 previous laparotomies who remarkably had no adhesions, or another with 10 previous operations, accessing the abdomen through the left upper quadrant has proven effective.
Remember, complications can arise from any part of a laparoscopic procedure, from patient positioning to the use of electrosurgical instruments. It’s vital to monitor and adjust techniques based on patient specifics like previous surgeries or body mass index.
Ultimately, recognizing and promptly addressing complications when they arise is crucial. Proper insufflation technique, careful trocar placement, and immediate complication management are key to successful laparoscopic surgery.
