An open Accesstechnique to creAtepneumoperitoneum in lApAroscopic

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					Scandinavian Journal of Surgery 96: 297–300, 2007




An open Access technique to creAte pneumoperitoneum
in lApAroscopic surgery

A.-c. moberg, u. petersson, A. montgomery
Department of Surgery, University Hospital of Malmö, Malmö, Sweden



AbstrAct

Background: An open access technique might reduce severe vascular and visceral injuries.
An open access technique through the umbilical cicatrix tube has been developed as a
routine method with the goal to be easy, safe and used by all surgeons in patients with-
out a previous midline incision.
   Aim: to evaluate the open technique in a prospective study in ��� consecutive laparo-
scopic operations regarding time for entrance, surgeons experience and bmi of the pa-
tients.
   Methods: A midline incision from the linea alba up into the inverted umbilicus was
performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow
into the abdominal cavity followed by a blunt trocar insertion.
   Results: time for access was median 93 seconds. entrance time in patients with bmi >
3� (n = �8) was ��� sec and with bmi < 3� it was 9� sec (p = �,7�). the median time for
consultants was 88 sec and for residents �2� sec (p = �,��3). no gas leakage was seen.
prolonged time for access was seen in three patients; two equipment failures and one
obese patent.
   Conclusion: the open access technique is applicable in all patients without a former
midline incision. it is fast, easy to learn with very few associated problems.
Key words: Open access; pneumoperitoneum; open laparoscopy; laparoscopy; open technique;
complication




InTrODUCTIOn                                              threatening. Injuries caused by blind port placement
                                                          might also be easier overlooked which might have
Laparoscopic surgery might produce technique spe-         disastrous effects. Open access techniques reduce the
cific complications. The use of Veress needle followed    incidence of vascular injuries to 0–0,03% (8).
by blind trocar placement, major injuries to large ves-      Hasson introduced the open technique in 1971 but
sels like the aorta, iliaca artery/vein and the vena      it did not become widely accepted perhaps because
cava have been reported in 0,003–0,08% of cases (2, 4,    it requires a mini laparotomy, which can be difficult
8). Visceral injuries occur in 0,04–4% (2, 4, 8). Al-     in obese patient’s (6). Other techniques for open ac-
though rare, theses complications are potentially life    cess using the umbilical cicatrix were then described
                                                          by Pawanindra et al (11). This technique is considered
                                                          safe and simple and is performed in about 240 sec-
                                                          onds. The time required for the Veress needle access
Correspondence:                                           is on average 214–300 seconds (1, 3, 5, 7).
  Ann-Cathrin Moberg, M.D.
  Department of Surgery                                      At our department the Veress technique was aban-
  University Hospital of Malmö                            doned in the late 1990’s and an open access technique
  SE - 205 02 Malmö, Sweden                               similar to the Pawanindra method, using the umbili-
  Email: address: ann-cathrin.moberg@skane.se             cal approach was developed (11). The goal was to
298                                           A.-C. Moberg, U. Petersson, A. Montgomery


create a safe open technique with a step-wise entrance              layers is used as follows;. a towel clip is applied in the
to the abdominal cavity, usable in all patients without             centre of the umbilicus, which is then inverted (Figs. 1, 2).
a previous midline laparotomy.                                      The assistant applies downward traction, and a transverse
   This study describes the operative technique and                 skin incision of a length corresponding to the diameter of
                                                                    the trocar is made in the umbilical fold. The umbilical cica-
evaluates its efficiency and use in obese patients.                 trix tube is dissected sharply down to the linea alba. A
                                                                    midline incision of appropriate length is made in the cica-
                                                                    trix tube extending craniallys with care taken only to incise
MATErIAL AnD METHODS                                                the fascialayer (Fig. 3). In obese patients, two S-shaped re-
                                                                    tractors can be used to facilitate this approach. The perito-
OPErATIVE TECHnIqUE                                                 neum is opened bluntly and the negative pressure allows
                                                                    air to flow into the abdominal cavity creating a distance
The technique can be applied supra or infra umbilically in          between the peritoneum and the intestines by upward trac-
patients with no previous midline laparotomy or incisions           tion with the towel clip (Fig. 4). The abdominal cavity is
including the umbilicus. A step-by-step entrance though all         then visualised. Finally a blunt, 10 mm, reusable trocar is
                                                                    placed through the incision into the abdominal cavity fol-
                                                                    lowed by insertion of the camera (Fig. 5). The same tech-
                                                                    nique can be applied in children using a 5 mm port. Insuf-
                                                                    flation is then initiated for the creation of pneumoperito-
                                                                    neum. If there is a problem with gas leakage, a towel clip
                                                                    can be applied to the skin adjacent to the trocar.
                                                                       At the end of the procedure, the towel clamp is again
                                                                    placed in the centre and the umbilicus is inverted. The
                                                                    fascia is exposed and closed with absorbable suture by an
                                                                    X-stitch followed by an intracutaneous suture.


                                                                    PATIEnTS

                                                                    One hundred consecutive patients without previous mid-
                                                                    line laparotomy were prospectively enrolled in the study.
                                                                    The operations were mainly laparoscopic cholecystectomies
                                                                    or appendectomies.
                                                                       Time from skin incision to the camera visualising the
                                                                    peritoneal cavity was recorded in seconds. The surgeon’s
Fig. 1. Midline section viewing the abdominal layers exposing the   status, consultant or resident, and complications associated
fascia going up into the umbilicus after inversion. The abdominal   with the open technique were registered. Age, sex and body
content follows the abdominal wall upward due to the negative       mass index (BMI) was registered. Obesity was defined as
pressure caused due to traction created by the towel clamp.         BMI > 30.




Fig. 2. Transverse skin incision after inversion of the umbilicus   Fig. 3. Longitudinal fascial incision through part of the linea alba
exposing the pillar down to linea alba.                             and upwards in the umbilical pillar.
                                                      Open access in laparoscopy                                                    299




Fig. 4. The peritoneum is penetrated using a blunt instrument al-    Fig. 5. A blunt reusable trocar is inserted into the abdominal cav-
lowing air to flow into the abdominal cavity creating a distance     ity during continued upward traction of the umbilicus in the space
between the peritoneum and intestines by upward traction with        between the abdominal wall and the intestines.
the towel clamp.




Statistics                                                           curve had to be passed simultaneously by many sur-
                                                                     geons resulting in an increase in major complications.
To detect a possible significant differences in operation time       Vascular and visceral injuries became focus also for
between consultants and residents and the difference in
operation time for obese and non-obese patients the Mann-
                                                                     the press in the early 1990ies. Champault et al de-
Whitney U test was used.                                             scribed an incidence of vascular injuries of 0,04% and
                                                                     visceral injuries of 0,06% in more than 100 000 pa-
                                                                     tients using the Veress technique (5).
rESULTS                                                                 A randomised controlled trial comparing blind ver-
                                                                     sus open approach requires 10 000 patients in each
Median age was 46 years (range 7–84) and 65% were                    group to detect a difference in serious complications
females. Eighteen surgeons (9 residents) participated.               and such a study does not exist. Guidelines from The
The consultants performed 68% of the operations.                     European Association for Endoscopic Surgerys con-
Median time for open access was 93 seconds (range                    clude that available data does not favour the use of
30–600). For consultants the median time was 88 sec                  either technique (11). However, they agree that major
(range 30–225) and for residents 120 sec (range 49–                  vascular injuries most often occur with the Veress
600) (p = 0,003). Eighteen patients were obese with a                approach.
median BMI of 31 (range 30–43). In these patients                       A meta-analysis by Merlin et al found vascular in-
(n = 18) the median time for access was 100 sec (range               juries in 0,003–1,33% using a blind technique and 0–
52–600) and in patients with BMI < 30 it was 90 sec                  0,03% using an open technique, whereas visceral in-
(range 30–480) (p = 0,71). In 74% of the operations,                 juries were found in 0,04% using the blind technique
open access was achieved within 2 minutes, 15% in                    and in 0–1,3% using the open technique (10). Vascular
2–3 minutes and in 11% more than 3 minutes were                      injuries can possibly be avoided with an open tech-
required.                                                            nique and the meta-analysis indicates a trend towards
   Gas leakage did not occur in any case. In two cases               a reduced risk of major complications for the open
the time for open access was prolonged due to techni-                access technique (10).
cal failure of the camera equipment and in one obese                    The open access technique was first described by
patient (BMI 37) the time to open access was 600sec.                 Hasson in 1971 and was recommended for patients
no injuries to intra-abdominal organs were seen.                     with previous laparotomies when adhesions were
                                                                     expected (8). It required a midline incision of up to
                                                                     3–4 centimetres. A special cone shaped trocar was
DISCUSSIOn                                                           used in order to minimise gas leakage. This method
                                                                     did not gain wide acceptance due to its complexity.
The Veress needle followed by blind trocar placement                 Hurd et al demonstrated a modification of the Has-
or direct trocar insertion without creating pneumo-                  son technique without using special instruments, but
peritoneum are the most common approaches to ac-                     reported problems with gas leakage in 14% and an
cess the abdominal cavity in laparoscopic surgery (4,                access time of 300 seconds compared to 230 sec using
5, 12). Laparoscopic surgery developed rapidly in the                the Veress technique (9). Their conclusion was to rec-
early 1990ies among general surgeons, paediatric sur-                ommend the use of the Veress technique routinely.
geons, gynaecologists and urologist’s. The learning                  Zaraca et al demonstrated a technique with a trans-
300                                     A.-C. Moberg, U. Petersson, A. Montgomery


verse fascial incision in the pillar of the umbilicus         rEFErEnCES
with a total entry time of 288 seconds (15). Pawanin-
dra et al used a technique similar to the one we have         01. Agresta F, DeSimon P, Ciardo LF, Bedin n: Direct trocar inser-
described in this study (13). We have used this tech-             tion vs Veress needle in nonobese patients undergoing lapa-
                                                                  roscopic procedures. Surg Endosc 18:1778–1781
nique since 1998 in a total of 4400 operations. All           02. Bernik Tr, Trocciola SM, Mayer DA, Patane J, Czura CJ, Wal-
surgeons and residents have completed an educa-                   lack MK: Ballon blunt-tip trocar for laparoscopic cholecystec-
tional program for the technique and the Veress nee-              tomy: improvement over the traditional Hasson and Veress
dle is virtually never used. Direct trocar insertion              needle methods. J Laparoendosc Adv Surg Tech 2001;11:73–
                                                                  78
(DTI) versus Veress needle are two other access tech-         03. Bonjer HJ, Hazebroek EJ, Kazemier G, Giuffrida MC, Meijer
niques evaluated in two recent randomised studies,                WS, Lange JF: Open vs closed establishment of pneumoperi-
including almost 600 patients each. These conclude                toneum in laparoscopic surgery. Br J Surg 1997;84:599–602
that DTI is easy and effective (7) and that Veress nee-       04. Borgatta L, Gruss L, Barad D, Kaali SG: Direct trocar insertion
                                                                  vs Veress needle use for laparoscopic sterilization. J reprod
dle use has unacceptable high incidence of complica-              Med 1990;35:891–894
tions (1). The optical access trocars provide a safe and      05. Champault G, Cazacu F, Taffinder N: Serious trocar accidents
rapid technique for initial trocar placement. results             in laparoscopic surgery: a French survey of 103 852 operations.
from a large series support the finding that few trocar           Surg Laparosc Endosc 1996;6:367–370
related complications were associated with the opti-          06. Cogliandodlo A, Manganaro T, Saitta FP, Micali B: Blind vs
                                                                  open approach to laparoscopic cholecystectomy: a randomized
cal access trocar (14). However, the open access trocar           study. Surg Laparosc Endosc 1998;8:353–355
is expensive and requires a zero degree optic, which          07. Gunenc DI, Yesildaglar n, Bringöl B, Önalan G, Tabak S, Gök-
is not useful for most laparoscopic operations.                   men B: The safety and efficacy of direct trocar insertion with
   The blind Veress technique requires 214–300 sec-               elevation of the rectus sheath instead of the skin for pneumo-
                                                                  peritoneum. Surg Laparosc Endosc Percutan Tech 2005;15:
onds for abdominal cavity access (2, 4, 6). The access            80–81
time was considerably shorter in our study (median            08. Hasson HM: A modified instrument and method for laparos-
93 seconds) compared to other studies (240–300 sec-               copy. Am J Obstet Gynecol 1971;110:886–887
onds) were open access has been used (9, 13, 15).             09. Hurd WW, randolph JF, Holmberg rA, Pearl ML, Hubbell GP:
                                                                  Open laparoscopy without special instruments or sutures,
Although time is not a primary objective it indicates             comparison with a closed technique. J reprod Med 1994;39:
the simplicity of the technique.                                  393–397
   The open access technique seems to be well ad-             10. Merlin TL, Hiller JE, Maddern GJ, Jamieson GG, Brown Ar,
opted among all 18 surgeons participating in this                 Kolbe A: Systematic review of the safety and effectiveness of
                                                                  methods used to establish pneumoperitoneum in laparoscop-
study even though the consultants performed the                   ic surgery. Br J Surg 2003;90:668–679
technique significantly faster than the residents. This       11. neudecker J, Sauerland S, neugebauer E, Bergamaschi r, Bon-
might be explained by the greater experience of the               jer HJ, Cuscheri, Fuchs K-H, Jacobi Ch, Jansen FW, Koivusalo
consultants. The time difference of only 32 seconds is            A-M, Lacy A, McMahon, MJ, Millat B, Schwenk, W: The euro-
hardly of any clinical relevance. The technique is ap-            pean association for endoscopic surgery clinical practice
                                                                  guideline on the pneumoperitoneum for laparoscopic surgery.
plicable in obese patients (BMI > 30) as well, with a             Surg Endosc 2002;16:1121–1143
median entry time of 100 seconds, although the group          12. Ostrzenski A: randomized prospective single-blind trial of a
was small (n = 18). One technical problem occurred                new parallel technique of veress pneumoperitoneum needle
causing prolonged access time in an obese patient.                insertion vs the conventional closed method. Fertility Sterility
                                                                  1999;71:578–581
Zaraca et al reported an access time of 570 sec in pa-        13. Pawanindra L, Sharma r, Chander J, ramteke VK: A technique
tients with a BMI above 30 with their technique (15).             for open trocar placement in laparoscopic surgery using the
This might indicate that the technique we are using               umbilical cicatrix tube. Surg Endosc 2002;16:1366–1370
is more applicable in obese patients. In two cases            14. Thomas MA, rha KH, Pinto PA, Montgomery rA, Kavoussi
                                                                  Lr, Jarrett TW: Optical access trocar injuries in urological
technical failure of the camera equipment caused a                laparoscopic surgery. J Urol 2003;170:61–63
prolonged time for entrance.                                  15. Zaraca F, Catarci M, Gossetti F, Mulieri G, Carboni M: routine
   In conclusion, the open access technique used in               use of open laparoscopy: 1006 consecutive cases. J Laparoen-
this study is applicable in all patients without a previ-         dosc Adv Tech 1999;9:75–80
ous laparotomy. It is fast and easy to learn with very
few associated problems. We strongly recommend
this technique for laparoscopic procedures.                   received: March 19, 2007
                                                              Accepted: October 11, 2007

ACKnOWLEDGEMEnT

Financial support from Helge B. Wulff´s foundation,
University of Lund, Lund, Sweden