Overview
Definition:
Safe entry techniques in laparoscopic surgery refer to the methods used to establish pneumoperitoneum, creating a working space within the abdominal cavity for minimally invasive procedures
The two primary techniques are Veress needle insufflation and open (Hasson) access.
Epidemiology:
Laparoscopic surgery is now the gold standard for many procedures
Establishing safe pneumoperitoneum is a critical first step in over 90% of abdominal surgeries, making understanding these techniques vital for all general surgical residents.
Clinical Significance:
Incorrect entry techniques can lead to serious intra-abdominal injuries, including bowel perforation, vascular damage, and omental tears, significantly increasing patient morbidity and mortality
Proficiency in both Veress and open access is crucial for safe surgical practice and successful examination performance.
Veress Needle Insufflation
Principle:
The Veress needle is a spring-loaded, blunt-tipped needle with a sharp outer cannula that penetrates the peritoneum
Once in the peritoneal cavity, a spring mechanism retracts the blunt tip, protecting underlying structures from the sharp cannula
CO2 gas is then introduced through the needle to create pneumoperitoneum.
Technique:
Typically performed at the umbilicus or a supraumbilical location
A small skin incision is made
The Veress needle is inserted perpendicular to the abdominal wall until resistance is lost, indicating peritoneal entry
Aspiration confirms intraperitoneal placement by checking for bowel contents or blood
Insufflation is then initiated, monitoring pressure and flow rates
A safe insufflation pressure is generally considered <12 mmHg.
Advantages:
Potentially faster initial insufflation
can be used in patients with previous adhesions
requires only a small incision for needle insertion.
Disadvantages:
Risk of visceral or vascular injury if not correctly placed
difficulty in confirming true intraperitoneal placement, especially in obese or scarred abdomens
inadequate insufflation can occur in the presence of adhesions
potential for gas leakage from the needle insertion site.
Open Access Hasson Technique
Principle:
The open (Hasson) technique involves creating a small incision, dissecting down to the fascia, incising the fascia, and then bluntly dissecting through the peritoneum
A blunt-tipped, radially expanding trocar is then inserted under direct vision into the peritoneal cavity.
Technique:
A curvilinear incision is made, usually periumbilical
Fascia is identified and incised
The peritoneum is grasped with Allis clamps and incised
The blunt trocar is inserted directly into the peritoneal cavity, and the pneumoperitoneum is established through this port under direct vision.
Advantages:
Direct visualization of all layers minimizes the risk of injury to underlying organs
easier to confirm correct placement
effective in patients with previous abdominal surgeries and adhesions
provides a secure port entry.
Disadvantages:
Slightly longer time to establish pneumoperitoneum
requires a slightly larger incision
potential for port site hernia if not closed properly.
Comparison And Selection Criteria
Indications For Veress:
Patients with no or minimal prior abdominal surgery
elective procedures where adhesions are unlikely
experienced surgeon.
Indications For Open Access:
Patients with a history of multiple abdominal surgeries
suspected significant adhesions
obese patients
previous failed Veress attempt
inexperienced surgeon
emergency laparoscopy.
Comparative Safety:
Studies show varying results, but open access is generally considered safer in patients with a history of adhesions due to direct visualization, reducing the risk of visceral/vascular injury.
Patient Factors:
Previous surgical history, obesity, and anatomical variations are key considerations in choosing the safest entry method.
Complications Of Entry
Visceral Injury:
Perforation of bowel, stomach, or bladder
Typically occurs with blind insertion methods like the Veress needle
Management involves immediate identification and repair.
Vascular Injury:
Damage to major vessels such as the aorta, vena cava, or mesenteric vessels
Can lead to significant hemorrhage and is a life-threatening complication
Requires prompt recognition and surgical intervention.
Omental Tear:
Tears in the omentum can occur during trocar insertion
Usually a minor complication but can lead to bleeding.
Port Site Hernia:
More common with larger trocars and open access if fascial closure is inadequate
Prevention involves meticulous fascial closure using appropriate sutures.
Gas Embolism:
Rare complication where CO2 enters the bloodstream, potentially leading to cardiovascular collapse
Prompt recognition and cessation of insufflation are critical.
Key Points
Exam Focus:
Understand the principles, steps, advantages, and disadvantages of both Veress needle and open access techniques
Be prepared to discuss indications and contraindications, especially in the context of previous surgeries and adhesions.
Clinical Pearls:
Always confirm intraperitoneal placement with Veress needle via aspiration and a gentle CO2 flow test
In open access, ensure direct visualization of all layers
If Veress fails, do not hesitate to convert to open access.
Common Mistakes:
Attempting Veress insufflation in a heavily scarred abdomen without prior suspicion of adhesions
inadequate fascial closure after port removal
not considering conversion to open access when initial attempts are difficult or risky.