SAFE ENTRY AND

PNEUMOPERITONEUM

Herbert Situmorang
Jakarta Center for Gynecology Endoscopy
Good entry / access :
 Pump up operator-confidence
 Better visualization
 Better ergonomics
 Less anaesthesia problems
 Less post operative problems
Major complication during 1000 laparoscopies
Major complication during 1000 laparoscopies

Asch R, Studd J, 1999

Scope of discussion
 Goal of peritoneal access
 Entry methodes
 Technical aspects in veress insertion and
insufflation
 Technical aspects in hasson’s open entry
Goal of peritoneal access
 Good visualization of the peritoneal cavity
 Ergonomic position of hand instruments
 Maintenance of patient safety :
vascular
visceral
incisional complication
 Cosmetically acceptable result : size, location
Methods
 Closed (Blind) Technique
- Veress needle: insufflation  optic trocar
- Direct trocar insertion : with trocar, without
trocar (ternamian)

 Open Technique (Hasson)

- Direct trocar insertion after incising the
fascia and peritoneum
Pre-entry Evaluation
 Abdominal Wall thickness
 Previous surgery
 Possibility of severe adhesion
 Equipments : veress needle, trocars type
 Operating table height
Closed technique- veress
 Veress needle selection
 Veress needle test, grip
 Patient’s position
 Umbilical incision
 Abdominal wall lifting technique
 Veress needle insertion
 Confirmation of veress position
Veress needle selection
 Options : 12-14-16 cm length
 Determinant factor : abdominal wall
thickness
 Check the spring mechanism and the
patency : VITAL !!
Veress grip
 Hold the veress needle like a dart
Patient’s position
 FLAT !
 Trendelenburg position : difficult to
estimate the proper angle of veress/trocar
insertion
Umbilical incision
 Transverse incision (Inferior border)
 Vertical incision
 Transumbilical

 Small incision vs wide incision

Risk : injury of incision to visceral organs !

Abdominal wall lifting
 Use of towel clips or Ellis clamp
Advantages :
stabilize the umbilicus :
- prevents intraperitoneal incision
- prevents overshoot of veres/trocar insertion
Disadvantages :
more scar and post op pain
false safety : peritoneum is not lifted by doing
this
Abdominal wall lifting
 Use of surgeon’s left hand :
advantage :
no additional scar / pain
disadvantage :
smaller hand cannot hold the abd firmly
folding of fascia
 Alternatives : both surgeon and first assistant’s
hand lift the abdomen side by side
Veress needle insertion
 Put the needle tip inside the incision, then
lift the abdomen
 Insert the veress in 45o elevation angle
and perpendicular to the abdominal wall


 FEEL the 2 “CLICK SOUND”

Confirmation of veress position
 Waggle test : veress needle movement
 Irrigation test
 Aspiration test
 Hanging drop test
 Insufflator indicators
Automatic insufflator indicator

Intraperitoneal pressure

CO2 Flow

Total gas used

Slow insufflation with careful hold
over veress needle

Look at the indicators carefully !

Trocar insertion
Reducing risk :
 Anatomy
 Ergonomics
 Insertion dynamics
 Abdominal pressure
Trocar grip
Lift abdominal wall as much as possible

Insert the trocar carefully

Primary trocar insertion
 Lower the operating table as low as it can
 Two giveways: fascia and peritoneum
 Whoozing sound
 Use as minimum power as possible
 Abdominal pressure : can be raised up to
25 mmHg without any side effect (Tsaltas,
Reich, 2000)
Trocar insertion
 Put the trocar tip JUST inside the
abdoment !!
Push the canulae further only after we retract
the trocar
Insert the camera

Do not turn the CO2 flow

on before you see the
internal abdomen !
Accessory trocar