Laparoscopy and entry

RCOG Basic Practical Skills Course

 Laparoscopic entry techniques

What to expect:
1. Position of patient
2. Primary port closed entry
3. Secondary port entry
4. Primary port alternatives
5. Exit techniques
6. Reference to RCOG Green Top Guideline 49 -
PREVENTING ENTRY-RELATED GYNAECOLOGICAL
LAPAROSCOPIC INJURIES

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 1. Position

• Prone
• Stirrups/Lloyd Davis
• Non slip mattress
• Trendelenberg after ports

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 Green-top Guideline. No. 49 May 2008

• The operating table should be horizontal (not in

the Trendelenberg tilt) at the start of the
procedure

• The abdomen should be palpated to check for

any masses before insertion of the Veress
needle

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 2. Primary port closed
entry
Why intra umbilical entry?

Fixed peritoneum
Thin
Least vascular
Cosmetic

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 Green-top Guideline. No. 49 May 2008

• The primary incision for laparoscopy should be

vertical from the base of the umbilicus (not in the
skin below the umbilicus)

• Care should be taken not to incise so deeply as to

enter the peritoneal cavity.

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 2. Primary port closed
entry
Insertion of Veress needle
Pencil grip
Vertical, then towards pelvis
Double “click”

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Green-top Guideline. No. 49 May 2008

• The Veress needle should be sharp, with

a good and tested spring action. A
disposable needle is recommended

• The lower abdominal wall should be

stabilised in such a way that the Veress
needle can be inserted at right angles to
the skin

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Green-top Guideline. No. 49 May 2008

• Two audible clicks are usually heard as the

layers of the umbilicus are penetrated.

• Excessive lateral movement of the needle

should be avoided. This may convert a small
needle point injury in the wall of the bowel or
vessel into a complex tear

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2. Primary port closed entry

Saline test
Withdraw
Instil
Withdraw

If no fluid, frank blood (or faeces) then

proceed with insufflation
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Green-top Guideline. No. 49 May 2008

• The saline test not 100% accurate

• The most valuable test of correct placement

of the Veress needle is to observe that the
initial insufflation pressure is relatively low
(less than 8mmHg) and is flowing freely

• After 2 failed attempts to insert the Veress

needle, either the open Hasson technique
or Palmer’s point entry should be used.
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2. Primary port closed entry

Insufflation
Set pressure cut off to at least 20-25mmHg
Start at low flow (1L/min)
Check gas entering at low pressure (<8mmHg)
After 0.5L flow rate can be increased
Insufflate to pressure cut off (20-25mmHg)

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2. Primary port closed entry
The greater the gas bubble & abdominal wall
tension the less the risk of bowel injury

Abdominal pressure= 8mmHg Abdominal pressure=25mmHg

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Green-top Guideline. No. 49 May 2008

• An intra-abdominal pressure of 20–25

mmHg should be achieved before
inserting the primary trocar

• The distension pressure should be

reduced to 12–15 mmHg once the
insertion of the trocars is complete

© Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

• The primary trocar should be inserted at 90

degrees to the skin, through the incision at
the base of the umbilicus

• Once the laparoscope has been introduced it

should be rotated through 360 degrees to
check for any adherent bowel

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2. Primary port closed
entry
Commonest problem - failed entry

Insertion of subumbilical Veress needle

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2. Primary port closed entry

Closed entry can still cause bowel injury,

especially if adhesions are present

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2. Primary port closed
entry
Other injuries
– Vascular injury
– Retroperitoneal
haemorrhage
– Bladder injury
– Injury to over inflated
stomach

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3. Secondary ports

Secondary ports are inserted under direct

vision - an inadvertent injury from a
secondary port could be considered
negligent”

Principles
Avoid inferior epigastric vessels
Avoid bowel/vascular injury
Minimise hernia risk

© Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

• Secondary ports inserted under direct

vision at right angles to the skin at 20–25
mmHg pneumoperitoneum

• Inferior epigastric vessels should be

visualised laparoscopically prior to
secondary port placement

• Once the trocar has pierced the

peritoneum it should be angled towards
the anterior pelvis
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3. Secondary ports - Anatomy

Mid-line

Rectus muscles

Obliterated umbilical artery

Round ligament

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3. Secondary ports - Anatomy

Inf epigastric artery

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4. Primary port – Alternatives
Alternatives to closed umbilical entry
considered:
If there is risk of umbilical adhesions - previous
(midline) laparotomy
In very slim or morbidly obese women
Failed saline test or Veress insertion x2
Unsatisfactory closed Veress insufflation

Alternatives include:
Open entry – variations of Hassan technique
Palmer’s point closed entry

© Royal College of Obstetricians and Gynaecologists

Green-top Guideline. No. 49 May 2008

• When Hasson open laparoscopic entry is

employed, confirm that the peritoneum has
been opened by visualising bowel or
omentum

• Palmer’s point is the preferred alternative

trocar insertion site, except in cases of
previous surgery in this area or
splenomegaly.

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5. Exit techniques

Under direct view to identify:

Bleeding

Injury to omentum

Injury to bowel
- (partial/complete)

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Green-top Guideline. No. 49 May 2008

• On removal of a laparoscope. Check by

direct visualisation that there has not
been a through-and-through injury of
bowel adherent under the umbilicus

• Secondary ports must be removed under

direct vision to ensure that any
haemorrhage can be observed and
treated, if present.

© Royal College of Obstetricians and Gynaecologists

5. Exit techniques

Wound closure:
Proper closure of fascia within umbilical
port site to prevent wound dehiscence or
hernia
Avoid hernia risk by closing sheath:
- Midline port sites > 7mm
- Lateral port sites > 5 mm

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Now show the Video: Closed
laparoscopic entry technique

Now show the video: Alternative

laparoscopic entry techniques

© Royal College of Obstetricians and Gynaecologists