You are on page 1of 4

MO DI FI CATI O N S O F THE CL OSE D TE CH NI Q U E

Optical Veress as an entry technique


P. McGurgan and P. O’Donovan
M.E.R.I.T. Centre, Bradford Royal Infirmary, Bradford, UK

Keywords ABS TR ACT

laparoscopy, mini/micro, optical, Objective To review the advances in instruments designed for safer entry
review, safety, Veress. into the abdominal cavity.
Design A systematic review of the literature, including a Medline search of
the period from 1966 to February 1999, using the words: laparoscopic, mini,
micro, entry, Veress needle, optical, safety and methods.
Results There are approximately 0.4 Veress needle-related injuries per 1000
procedures. The modified ‘optical’ Veress instruments are designed to
further decrease this rate. Despite extensive studies demonstrating the use
of the latter, there are no large-scale, well-designed trials to confirm their
superiority over the conventional Veress.
Correspondence Conclusion Veress needle-related injuries are rare, but their sequelae can be
P. O’Donovan, M.E.R.I.T. Centre, Bradford
fatal. Many of the alternative instruments have potential advantages over the
Royal Infirmary, Bradford BD9 6RJ, UK.
Veress needle, but lack of quality research means that they are not yet
Accepted for publication 10 June 1999 validated. This must be done by well-planned trials as soon as possible.

We can see that entry-related complications are


INTRO DUCTIO N
relatively infrequent.11–16 Nevertheless, there is no
The Veress started life as an instrument for creating room for complacency; complications rare in the
pneumothoraces in cases of pulmonary tuberculosis, experience of individual surgeons can still represent a
being invented by the respiratory physician, János major problem on an international scale. Of particular
Veress in the 1930s1 The simple design, comprising a concern is the fact that the rates for haemorrhagic and
blunt-tipped, spring-loaded inner stylet and a sharp perforation complications are roughly equal for the
outer needle of up to 16 gauge, was eagerly seized Veress needle and for the trocar.
upon by gynaecologists in the mid-20th century as a What are the alternatives? There is an abundance of
safe instrument for the creation of a pneumoperito- texts and papers describing ‘safe’ techniques for laparo-
neum.2 Many different methods for the creation of scopy,3,16–18 but for the purpose of this article, we have
pneumoperitoneum have since been reported.3 Never- focused on a systematic review of the literature on
theless, the use of the Veress needle followed by blind instruments which are described as improvements on
trocar insertion probably remains the most common the Veress needle.
method, being taught to most practising gynaecologists
during their training.
ME TH ODS
The technique, however, is associated with a number
of complications,4–10 mainly because the peritoneum We performed a literature search for relevant papers and
might not be entered during the blind insertion, and articles from our own library, along with a Medline
also more seriously, despite the protective spring- search from 1966 to February 1999 using the words:
loaded stylet, the instrument may cause inadvertent laparoscopic, mini, micro, entry, Veress needle, optical,
injury. The frequency of major complications is difficult safety and methods. Papers were reviewed with emphasis
to determine, and various rates are quoted (Table 1). on the quality of their methodology and statistical

q1999 Blackwell Science Ltd Gynaecological Endoscopy 1999 8, 379–382 379


380 P. MCGURGAN & P. O ’DON OVAN

Table 1 Large studies of injuries associated with the Veress needle/trocar4

Study No. of Haemorrhagic Visceral Rate per 1000 cases


laparoscopies complications perforation

Querleu et al.5 17 521 4 Veress/trocar 7 Veress/trocar 0.63


Mintz6 99 204 25 Veress 5 Veress 0.30
18 trocar 26 trocar
Bergqvist & Bergvist7 75 035 4 Veress Not reported 0.07
1 trocar
Jansen8 25 764 5 Veress injuries 0.19
68 trocar

analysis, and the theoretical and practical evidence UK),22–25 which is very similar to the usual disposable
for the superiority of the instrument over the Veress Veress. All the instruments use minilaparoscopes, which
needle. fit into the ‘sleeve’ of an adapted Veress-type needle.
The Optical Veress has a diameter of 2.1 mm and is
10.5 cm long. It is usually inserted by means of the
R E S U LTS
conventional technique and uses a 1.2-mm diameter
The results of our literature review and liaison with semirigid fibreoptic minilaparoscope (Fig. 1). Similarly,
companies involved in developing alternatives for the the Microlap has a 2-mm diameter and is 14 cm long; it
Veress needle demonstrated the drive to develop instru- uses a 1.98-mm fibreoptic laparoscope, and has an
ments which can replace the conventional device. The anchor engagement device at the distal end to prevent
first optical Veress insruments were developed in the accidental displacement once peritoneal entry is con-
mid-1990s,19 and their introduction has produced firmed (Fig. 2). These instruments remove much of the
reports from many centres (26 Medline citations) uncertainty (and time) associated with the various
advocating their use. indirect tests which are conventionally used to confirm
Modified ‘optical’ Veress instruments attempt to intraperitoneal entry. However, an initially blind tech-
increase the safety of laparoscopic entry by taking nique is still used to gain entry into the cavity, and the
advantage of developments in fibreoptics. The first time required for insufflation can be long if only the
modified Veress was produced by Karl Storz (Tuttlin- Optical Veress is used.
gen, Germany) as the Optical Veress, and there now are As at other centres, we have modified this technique
a variety of instruments on the market. Our experience somewhat by using the Optical Veress at Palmer’s point
has been with the Optical Veress,20–22 a reusable robust in our high risk patients.20,26–28
device, and the Microlap (Nikomed, Hampshire, The small calibre of these instruments, combined
with surprisingly good image quality, has led to the

Figure 1 The Optical Veress (Karl Storz, Tuttlingen,


Germany). Figure 2 The Microlap (Nikomed, Hampshire, UK).

Gynaecological Endoscopy 1999 8, 379–382 q1999 Blackwell Science Ltd


OPTICAL V ERE SS AS AN E NTR Y TE CHNIQUE 381

development of micro/minilaparoscopy with conscious 4 Rosen D, Lam AM, Chapman M, et al. Methods of
patients, particularly in the US managed patient care creating pneumopreitoneum. Obstetrical and Gynecological
Survey 1998; 53 (3): 167–74.
system.29–31 This is a controversial area in laparoscopic
5 Querleu D, Chevallier L, Chapron C, Bruhat MA.
surgery at the moment, and we await evidence of its Complications of gynaecological laparoscopic surgery. A
superiority over conventional laparoscopy under French collaborative study. Gynaecological Endoscopy 1993;
general anaesthesia (with all its attendant risks) before 2: 3–6.
attempting this approach. 6 Mintz M. Risks and prophylaxis in laparoscopy: a survey
Our literature search, through Medline and our own of 100,000 cases. Journal of Reproductive Medicine 1977; 18:
269–72.
library, concerning the above instruments revealed 7 Bergvist D, Bergvist A. Vascular injuries during
many papers discussing the techniques in great detail; gynecologic surgery. Acta Obstetricia et Gynecologica
however, the data tended to be nonrandomized and Scandinavica 1987; 66: 19–23.
involve small numbers, precluding any statistical inter- 8 Jansen FW, et al. Complications of laparoscopy: a
pretation. Therefore, whilst there is obviously a great prospective multicentre observational study. British
Journal of Obstetrics and Gynaecology 1997; 104: 595–600.
deal of interest in these instruments designed to
9 Loffer FD, Pent D. Indications and contraindications
increase the safety of laparoscopy, and although they and complications of laparoscopy. Obstetrical and
certainly possess practical and theoretical advantages, Gynecological Survey 1975; 30: 407–23.
there is still a lack of any hard evidence with which to 10 Tsaltas J, Healy DL, Lloyd D. Review of major
compare their safety with that of the conventional complications of laparoscopy in a free standing
gynecologic day case hospital. Gynaecological Endoscopy
Veress.
1996; 5: 265–70.
11 Chamberlain G, Carron Brown JA. Royal College of
Obstetricians and Gynaecologists’ Report on the Confidential
CONCLUSIONS Enquiry into Gynaecological Laparoscopy. London: RCOG
Press, 1978.
Veress needle-related injuries are rare, approximately 12 Royal College of Obstetricians and Gynaecologists. Report
0.4 per 1000 procedures based on the average of the of the RCOG Working Party on Training in Gynaecological
reported studies in Table 1. However their sequelae can Endoscopic Surgery. London: RCOG Press, 1994.
be fatal, and our study has demonstrated the drive to 13 Peterson HB, Hulka JF, Phillips JM. American
develop instruments which can replace the conven- Association of Gynecologic Laparoscopists’ Survey, 1972–
93. Journal of the American Association of Gynecologic
tional device. Laparoscopists 1990; 35: 587–9.
One of the current contradictions in minimal access 14 Pierre F, Chapron C, de Poncherville L. French survey
surgery is that whilst tremendous advances have been on gynaecologic laparoscopy. Human Reproduction 1998;
made in the ability to perform complicated procedures, 13 (7): 1761.
we still have no consensus on the optimal techniques 15 Goodwin H. Minimal access surgery. Journal of the MDU
1998; 14 (1): 2–12.
for carrying out basic and safe laparoscopic surgery. All
16 Garry R. Complications of laparoscopic entry.
the alternative instruments discussed have potential Gynaecological Endoscopy 1997; 6: 319–29.
advantages over the Veress needle, but lack of quality 17 Sutton CJ. A practical approach to laparoscopy. In:
research means that their superior safety compared Sutton CJ, Diamond M, eds. Endoscopic Surgery for
with the Veress is not yet proven. We have a responsi- Gynaecologists. 2nd edn. London: W.B. Saunders, 1998,
41–53.
bility to ensure that internationally agreed, safe
18 Phipps JH. Complications of laparoscopic surgery.
methods of achieving laparoscopic entry are obtained Avoidance and management. Yearbook of the Royal College
through good quality large-scale trials, as a matter of of Obstetrics and Gynaecology London: RCOG, 1995; 67–78.
urgency. 19 Schaller G, Kuenkel M, Manegold BC. The ‘optical
Veress-needle’. Endoscopic Surgery and Allied Technologies
1995; 3 (1): 55–7.
20 Okeahialam MG, O’Donovan PJ, Gupta JK.
R EF E RE N CE S
Microlaparoscopy using an optical veress needle inserted
1 Veress J. Neues instrument sur Ausfuhrung von Brust- at Palmer’s point. Gynaecological Endoscopy 1999; 8: 115–6.
oder. Deutsche Medizinische Wochenschrift 1938; 64: 1480–1. 21 Fuller PN. Microendoscopic surgery. American Journal of
2 Baskett TF. On the Shoulders of Giants. London: RCOG Obstetrics and Gynecology 1996; 174: 1757–61.
Press, 1996. 22 Audebert AJM. The role of microlaparoscopy for safer
3 Hill DJ. Complications of the laparoscopic approach. wall entry: incidence of umbilical adhesions according to
Baillière’s. Clinical Obstetrics and Gynaecology 1994; 8: 865– past surgical history. Gynaecological Endoscopy 1999; 8:
79. 363–7.

q1999 Blackwell Science Ltd Gynaecological Endoscopy 1999 8, 379–382


382 P. MCGURGAN & P. O ’DON OVAN

23 Downing BG, Wood C. Initial experience with a new 28 Reich H, Levie M, McGlynn F, et al. Establishment of
2 mm microloaparoscope. Australian and New Zealand pneumoperitoneum through the left ninth intercostal
Journal of Obstetrics and Gynaecology 1995; 35 (2): 202. space. Gynaecological Endoscopy 1995; 4: 141–3.
24 Faber BM, Coddington CC. Microlaparoscopy: a 29 Love BR, McCorvey R, McCorvey M. Low cost office
comparative study of diagnostic accuracy. Fertility and laparoscopic sterilisation. Journal of the American
Sterility 1997; 67 (5): 952–4. Association of Gynecologic Laparoscopists 1994; 1: 379–81.
25 Hauesler G, et al. Diagnostic accuracy of 2 mm 30 Risquez F, Pennehoaut G, McCorvey R, et al. Diagnostic
microlaparoscopy. Acta Obstetricia et Gynecologica and operative laparoscopy: a preliminary multicentre
Scandinavica 1996; 75: 672–5. report. Human Reproduction 1997; 12 (8): 1645–8.
26 Bauer O, et al. Small diameter laparoscopy using a 31 Palter SF, Olive DL. Office microlaparoscopy. Journal of
laparoscope. Journal of Of Assisted Reproduction and the American Association of Gynecologic Laparoscopists 1996; 3
Genetics 1996; 13 (4): 298–306. (3): 359–64.
27 Palmer R. Safety in laparoscopy. Journal of Reproductive
Medicine 1974; 3: 1–5.

Gynaecological Endoscopy 1999 8, 379–382 q1999 Blackwell Science Ltd