Prof. Dr. R. K. Mishra INTRODUCTION Minimal access surgery (MAS) a new surgical and interventional approach, was called by different name and one of the popular is minimally invasive surgery. However, unique complications are associated with gaining access to the abdomen for laparoscopic surgery. The technique of first entry inside the human body with telescope and instruments is called access technique. The hallmark of the new approaches is the reduction in the trauma of access. The technique for access to the peritoneal cavity, choice of access technique, placement locations, and port placement is very important in MAS. Technique of access is different for different minimal access surgical procedures. Thoracoscopy, retroperitoneoscopy, axilloscopy, and arthroscopy all have different ways of access. In this chapter, we will discuss various abdominal access techniques. It is important to know that approximately 20% of laparoscopic complications are caused at the time of initial access. Developing access skill is one of the important achievements for the surgeon practicing MAS. First entry or access in laparoscopy is of two types: (1) closed access and (2) open access. ANATOMY OF ANTERIOR ABDOMINAL WALL Knowledge of the surgical anatomy of the abdominal wall is essential for the safe access in laparoscopic surgery. Laparoscopic instruments traverse the skin, subcutaneous fat, variable myofascial layers, preperitoneal fat, and parietal peritoneum. There are three large, flat muscles (external oblique, internal oblique, and transversus abdominis) and one long vertically oriented segmental muscle (rectus abdominis) on each side. The layers of the abdominal wall in the midline include skin, subcutaneous fat, and a fascial layer (linea alba) that is a coalescence of the anterior and posterior rectus sheath. Four major arteries on each side are also present which form an anastomotic arcade that supplies the abdominal wall. The superior and inferior epigastric artery and the branches provide the major blood supply to the rectus abdominis muscle and other medial structures (Fig. 1). Fig. 1: Anterior abdominal wall anatomy. Among all these arteries, the most important for laparoscopic surgeon is the inferior epigastric artery and vein. The inferior epigastric vessel landmark is less variable compared to superior epigastric. Bleeding from inferior epigastric is a big problem because it is larger in diameter than superior epigastric. Umbilicus is the site of choice for access in majority of laparoscopic procedure. The umbilicus is a fusion of fascial layers and is devoid of subcutaneous fat. The median umbilical ligament which is obliterated urachus and paired medial umbilical ligaments, i.e., obliterated umbilical arteries are peritoneal folds that join at the inferior crease of the umbilicus, forming a tough layer. This umbilical tube scar remains after the umbilical cord obliterates which makes an attractive site of primary access of Veress needle and trocar. At the level of umbilicus, skin fascia and peritoneum are fused together, with the minimum fat. The midline of abdominal wall is free of muscle fibers, nerves and vessels except at its inferior edge where pyramidalis muscle is sometimes found. Therefore, Veress needle or trocar insertion in these locations rarely cause much bleeding. If a defect in the umbilical fascia suggests an umbilical hernia or
SECTION 1: Essentials of Laparoscopy if any midline incision scar of previous laparoscopy is found or if any anomalies of the urachus may also exist umbilicus should not be used for primary access. If an umbilical hernia or urachal anomaly is suspected, alternative access sites may need to be considered. The colon is attached to the lateral abdominal wall along both gutters and puncture laterally for secondary trocars should be under video control to avoid visceral injury. When left subcostal site is chosen for access it should be 2 cm below the costal margin in midclavicular line called Palmer’s point. The costal margin provides good resistance as the needle is introduced. When puncture site lateral to the midline is used, it is prudent to choose location lateral to the linea semilunaris to avoid injury of superior and inferior epigastric vessels. In obese patients, the linea semilunaris may not be visible. In these, location of inferior artery can be localized by careful transillumination. Access to preperitoneal space is gained by penetrating almost all the layers of abdominal wall except peritoneum. The open technique of access is preferable in this situation. After incising the fascia with the scalpel, fingered dissection is advisable to avoid puncture of peritoneum. CLOSED ACCESS TECHNIQUE To start any laparoscopic procedure the peritoneal cavity needs to be accessed, first to establish pneumoperitoneum and subsequently to place a port for the laparoscope and add the placement of additional ports for various laparoscopic instruments. In closed access technique, pneumoperitoneum is created by Veress needle (named for Janos Veress) (Fig. 2). The Veress needle was originally developed by Janos Veress to give patients with tuberculosis iatrogenic pneumothorax without damaging the underlying lung parenchyma (Fig. 3). It has a small-bore (1.8–2.2 mm) needle with a spring-loaded protective obturator with a side hole that recoils to cover the end of the needle, allowing entry into a body cavity without traumatizing the underlying organs (Fig. 4). Maximum flow of gas through the eye of Veress needle is 2.5 L/min only but for safety it should be kept at 1 L/min to prevent accidental gas embolism (Fig. 5). This is a blind technique and most practiced way of access by surgeons and gynecologists worldwide. When choosing site of closed access, previous surgical incisions, or any anatomical abnormality, should be noted. Sites that have not been previously instrumented are preferred for initial access. Closed technique of access merely by Veress needle insertion and creation of pneumoperitoneum is an easy way of access but it is not possible in some of the minimal access surgical procedures such as axilloscopy, retroperitoneoscopy, and totally extraperitoneal approach of hernia repair. In general, closed technique by Veress needle is possible only if there is a preformed cavity like abdomen. Creation of pneumoperitoneum is one of the most important steps in laparoscopy. The aim is to build up a good protective cushion of gas to ensure the safe entry of trocar and cannula. Veress Needle Insertion The standard method of insufflations of the abdominal cavity is via a Veress needle inserted through a small skin incision over inferior crease of umbilicus. Disposable and reusable metal Veress needles are available commercially in different lengths (8–20 cm), i.e., long for obese patients, short for thin or pediatric patients. Before using Veress needle, it should be checked for its patency and spring action. Spring action of Veress needle can be checked by pulling the head out. The disposable Fig. 3: Veress needle. Fig. 2: Veress needle inventor—Janos Veress. Fig. 4: Parts of Veress needle.
Operating Room Setup Fig. 5: Eye of Veress needle. Veress needle spring action can be checked by pressing the sharp end against any sterilized draping. Insufflation via the Veress needle creates a cushion of gas over the bowel for insertion of the first trocar. Insufflation then retracts the anterior abdominal wall, exposing the operative field. Preparation of Patient The patient should be nil orally since the morning of surgery. In some of the procedure such as laparoscopic hysterectomy or colorectal surgery where distended bowel may interfere, it is good to prepare bowel prior to the night of surgery by giving some mild purgative (polyethylene glycol). Bowel preparation can minimize the need of accessory port to retract the bowel. Before coming to operation theater, patient should always void urine. The full urinary bladder may get perforation at the time of insertion of Veress needle or trocar. If the laparoscopic procedure is of short duration and is going to be performed of upper abdomen, then Foley catheterization is not necessary. If gynecological operative surgery or any major general surgical lower abdominal procedure has to be performed (such as hernia or adhesiolysis), it is wise to insert Foley catheter. If surgeon is going to perform any upper abdominal procedures such as cholecystectomy, fundoplication, duodenal perforation, hiatus hernia, etc., it is good practice to have nasogastric tube in place. A distended stomach will not allow proper visualization of Calot’s triangle and then surgeon has to apply more traction over fundus or Hartmann’s pouch, and this may cause tenting of common bile duct (CBD) followed by accidental injury. In gynecological or lower abdominal minor laparoscopic procedure, it is not necessary to put nasogastric tube. In MAS, shaving of skin is not must and if necessary, it should be done on operation table itself by surgeon. An organized well-equipped operation theater is essential for successful laparoscopy. The entire surgical team should be familiar with the instruments and their function. Each instrument should be inspected periodically for loose or broken tips even if the same instrument was used during a previous procedure. It is necessary to confirm proper sterilization of instruments because the surgeon ultimately is responsible for the proper functioning of all instrument and equipment. The entire instrument should be placed according to wish of the surgeon so that it should be ergonomically perfect for that surgery. The coaxial alignment should be maintained. Coaxial alignment means the eye of the surgeon, target of dissection, and monitor should be placed in same axis. Patient Position Initially at the time of pneumoperitoneum by Veress needle, patient should be placed supine with 15° head down. The benefit of this Trendelenburg’s position is that bowel will be pulled up and there will be more room in pelvic cavity for safe entry of Veress needle. It is important to remember that patient should be placed in head-down position only if surgeon is planning to insert Veress needle pointing toward pelvis cavity. If surgeon is planning to insert Veress needle perpendicular to abdominal wall as in case of very obese patient, previous midline incision or diagnostic laparoscopy in local anesthesia, the patient should be placed in supine position otherwise all the bowel will come just below the umbilicus and there is increased risk of bowel injury. In gynecological laparoscopic procedures or if laparoscopy is planned to be performed together with hysteroscopy, patient should be positioned in lithotomy position and one assistant should be positioned between the leg of patient (Fig. 6). Patient’s leg should be comfortably supported by padded obstetric leg holders or Allen stirrups which minimize the risk of venous thrombosis. In these procedures, surgeon needs to use uterine manipulator for proper visualization of female reproductive organs. The assistant seating between the legs of patient will keep on watching the hand movement of surgeon on monitor and he should give traction with the handle of uterine monitor in appropriate direction. If thoracoscopy or retroperitoneoscopy is planned, then patient is placed in lateral position (Fig. 7). Position of Surgical Team The laparoscopic surgeon is very much dependent and helpless with eye fixed on monitor. At the time of laparoscopic surgery, surgeon is largely depending on his correct standing position. If the surgery is of upper abdomen, French surgeons like to stand between the legs of patient, popularly known as 77
SECTION 1: Essentials of Laparoscopy Fig. 6: Patient position in gynecological laparoscopy. A Fig. 7: Patient position in retroperitoneoscopy. B Figs. 8A and B: American versus French position. “French position” (Figs. 8A and B). The American surgeons like to operate from left in cases of upper abdominal surgery such as cholecystectomy called as “American position” . It is not always wise to remain standing in any one fixed position and surgeon can walk to the other side of operation table to achieve proper ergonomics. In most of the cases at the time of initial access, right-handed surgeon should stand on left side of the patient so that he can hold the Veress needle with right dominant hand. If surgeon is left-handed, he should stand right to the patient at the time of access and insert the Veress needle or trocar with left hand. This helps in inserting Veress needle and trocar toward pelvis by dominant hand. Once the initial Veress needle and first optical trocar has been introduced surgeon should stand opposite to the organ which he wants to operate on. Once all the ports are in position, the surgeon should come opposite to the side of pathology to start surgery and he should achieve coaxial alignment means eye of the surgeon, target of dissection, and center of monitor should be in one linear axis. In cholecystectomy, appendectomy, right-sided hernia or right ovarian cyst, surgeon should stand left to the patient. In left-sided pathology such as left ovarian cyst and left-sided Fig. 9: Surgeons stands left to the patient in most of the right-sided pathology. hernia, it is ergonomically better for surgeon to stand right to the patient (Fig. 9). In most of the upper abdominal surgery, camera assistant should stand left to the surgeon and in lower abdominal surgery, he or she should stand right to the surgeon. Camera
assistant while holding telescope can pass his or her hand between body and arm of surgeon so that sometime surgeon can help him to focus his camera correctly. Camera assistant can be placed opposite to the surgeon to stand but in this case, it is better to have two monitors on both the side of patient, one for surgeon and one for camera stand and other members of surgical team. The surgeon should work in the most comfortable and less tiring position possible with shoulder relaxed, arms alongside of the body, elbows at 90° angle and forearm horizontal. Before starting access, abdomen should be examined for any palpable lump. It is wise to tell the patient to void urine before coming to operating room but if the bladder is found full at the time of palpation. Foley catheter and nasogastric tube should be applied once patient is anesthetized. Remember that full bladder or distended stomach may be injured very easily by Veress needle or trocar. Once the patient is cleaned painted and draped, all the connection should be attached, followed by focusing and white balancing of camera. At the time of focusing, the distance between the gauge piece and tip of the telescope should be 6–8 cm. laser irradiation. For short operative procedures such as sterilization or drilling, under local anesthetic N 2O may also be used. During prolonged laparoscopic procedure, N2O should not be a preferred gas for pneumoperitoneum because it supports combustion better than air. CO2 when comes in contact with peritoneal fluid converts into carbonic acid. Carbonic acid irritates diaphragm causing shoulder tip pain and discomfort in abdomen. Carbonic acid has one advantage also that it alters pH of peritoneal fluid (acidotic changes) and it is mild antiseptic, so the chances of infection may be slightly less compared to any other gas. Helium gas being inert in nature is also tried in many centers, but it does not have any added benefit over CO2. Helium may be a suitable alternative to CO2 for creating pneumoperitoneum in patients with severe cardiorespiratory disease. Some of the study suggest that pneumoperitoneum with helium will not be associated with profound circulatory depression or oxygen transport abnormalities. In addition, the use of helium is not associated with acid-base disturbances, although central venous filling pressures are similarly increased as with the use of CO 2 pneumoperitoneum. However, helium is expensive gas and because of its low water solubility helium has a lower safety margin than CO2 in the event of gas embolism. Choice of Gas for Pneumoperitoneum Introduction of Veress Needle At first, pneumoperitoneum was created by filtered room air. Carbon dioxide (CO2) and nitrous oxide (N2O) are now preferred gas because of increased risk of air embolism with room air. CO2 is used for insufflation as it is 200 times more diffusible than oxygen and 20 times more absorbable than room air. It is rapidly cleared from the body by the lungs and will not support combustion. N2O is only 68% as rapidly absorbed in blood as CO2. N2O has one advantage over CO2 that it has mild analgesic effect, and hence no pain if diagnostic laparoscopy is performed under local anesthesia. CO2 has the advantage of being noncombustible and allows the concomitant use of electrocoagulation and To access the abdomen with a closed approach using a Veress needle: ■ Apply two Allis forceps to evert the inferior crease of umbilicus (Fig. 10). ■ Give a 2-mm smiling incision in the skin and the subcutaneous tissue over inferior crease of umbilicus (Fig. 11). ■ Hold shaft of the Veress needle as a dart (Fig. 12). ■ Guard the length of Veress needle needed to reach the peritoneal cavity (Fig. 13). ■ Place the needle through the incision to the level of the fascia (Fig. 14). Fig. 10: Two Allis forceps is applied over crease of umbilicus. Fig. 11: 2-mm stab wound over inferior crease of umbilicus. Preparation for Access 79
SECTION 1: Essentials of Laparoscopy Fig. 12: Veress needle should be held like a dart. Fig. 13: Guard the required length of Veress needle. ■ Grasp and elevate the abdominal wall with your left hand. It is important to note that grasping only the skin while not including the fascia may increase the rate of failed entry (Fig. 14). ■ Hold the Veress needle just over the previously incised site and insert it through the incision at a 45° angle toward anus but keep perpendicular to the abdominal wall. This can be only achieved by lifting the abdominal wall adequately by left hand (Fig. 14). ■ While inserting the Veress needle feel for two “pops” . The first occurs when the needle passes through the abdominal fascia and the second as it passes through the parietal peritoneum. More lateral access sites may have additional “pops” if more than one layer of fascia is traversed. ■ As soon as the needle enters the peritoneal space, the displaced hub of the needle will “click” as the protective sheath recoils to cover the end of the needle. After entering in abdominal cavity, the intra-abdominal needle will also move more freely than a needle within the abdominal wall. Veress needle should be held like a dart (Fig. 12). At the time of insertion, there should be 45° of elevation angle. Elevation angle is angle between instrument and body of patient. To get an elevation angle of 45° the distal end of the Veress needle should be pointed toward anus (Fig. 14). To prevent creation of preperitoneal slip of tip of Veress needle, it is necessary that Veress needle should be perpendicular to the abdominal wall. However, there is a fear of injury of great vessels or bowel if Veress needle is inserted perpendicular to the abdominal wall. To avoid both the difficulty (creation of preperitoneal space and injury to bowel or great vessels), the lower abdominal wall should be lifted in such a way that it should lie at 90° angle in relation to the Veress needle but in relation to the body of patient Veress needle will be at an angle of 45° pointed toward anus. Lifting of abdominal wall should be adequate so that the distance of abdominal wall from viscera should increase. If less than required dose of muscle relaxant is given in muscular patient, lifting of Fig. 14: Veress needle should be pointed toward anus but perpendicular to abdominal wall. abdominal wall may be difficult. In multipara patient, lifting lower abdominal wall is very easy. Several tests are available for confirming Veress needle placement. These include one of the following: Needle Movement Test Once the Veress needle is inside the abdominal cavity, the tip of Veress needle should be free and if surgeon will gently move the tip of needle there should not be feel of any resistance. It is very important to remember that Veress needle should not be moved inside the abdominal cavity much, otherwise there is a risk of laceration of bowel to be punctured. Irrigation Test A 10-mL syringe should be taken in one hand and surgeon should try to inject at least 5 mL of normal saline through Veress needle. If tip of Veress needle is inside the abdominal cavity, there will be free flow of saline otherwise some resistance is felt in injecting saline (Fig. 15). Aspiration Test After injecting saline, surgeon should try to aspirate that saline back through Veress needle (Fig. 16). If the tip of Veress
Fig. 15: Irrigation test. Fig. 16: Aspiration test. needle is in abdominal cavity, the irrigated water cannot be sucked. But if it is in preperitoneal space or in muscle fiber or above; the rectus the injected water can be aspirated back. In aspiration test, if more irrigated fluid is coming, then surgeon should suspect ascites, some cysts or perforation of urinary bladder. If fecal matter is seen then perforation of bowel may be the reason and if blood is coming then the vessel injury is the cause. If any fresh blood or fecal fluid is aspirated in the syringe, surgeon should not remove the Veress needle and urgent laparotomy is required. Leaving Veress needle in position is helpful in two ways. First, it is easy to find the punctured area after laparotomy and secondly, the further bleeding will be less. Few drops of saline should be poured over the Veress needle and abdominal wall should be lifted slightly, if tip of the Veress needle is inside the abdominal cavity the hanging drop should be sucked inside because inside the abdomen, there is negative pressure. If tip of the Veress needle is anywhere else, the hanging drop test will be negative (Figs. 17A and B). Once it is confirmed that Veress needle is inside the abdominal cavity, the tubing of insufflator is attached and flow is started. of lifting abdominal wall was advocated by Johns Hopkins University but after some time it was realized that towel clip technique increases the distance of skin from rest of the abdominal wall more than distance of abdominal wall from viscera. Abdominal wall should be held full thickness with the help of thenar, hypothenar and all the four fingers (Fig. 14). It is lifted in such a way that angle between Veress needles to abdominal wall should be 90° and angle between Veress needle and patient should be 45°. At the time of entry of Veress needle, surgeon can hear and feel two click sounds. The first click sound is due to rectus sheath and second click sound is due to puncture of peritoneum. Anterior and posterior rectus forms one sheath at the level of umbilicus, so there will be only one click for rectus. If any other area of abdominal wall is selected for access surgeon will get three click sounds. Once these two click sound is felt, surgeon should stop pushing Veress needle further inside and he should use various indicators to know how far he has accessed. Once the desire length of Veress needle is introduced in abdomen, the tubing of insufflator should be attached to Veress needle (Fig. 15). It is important to keep nice hold on Veress needle throughout while gas is flowing; otherwise Veress needle can slip out and may create preperitoneal insufflation (Fig. 16). Measurement of Intra-abdominal Pressure Insufflation of Gas Test, Quadromanometric Test Measure intra-abdominal pressure by attaching the Veress needle to the laparoscopic insufflator. An intra-abdominal position of the needle is suggested for intra-abdominal pressure ≤10 mm Hg. In one large observational study, confirmation of low intraperitoneal pressure was the most reliable method to confirm Veress needle placement. Once an intra-abdominal position of the needle is verified, initiate gas insufflation (typically CO2). A properly placed Veress needle will allow free flow of gas. Tympany should be appreciated with percussion of the abdomen in the right upper quadrant. For many years, surgeons have been using towel clip to elevate the abdominal wall. This towel clip technique Tubing of the insufflator should be tightly attached with the help of Luer lock of Veress needle (Figs. 18 and 19). For safe access, surgeon should always see carefully all the four indicators of insufflator at the time of creation of pneumoperitoneum. If the gas is flowing inside the abdominal cavity, there should be proportionate rise in actual pressure with total gas used. Suppose only with the entry of 200–300 mL of gas, if actual pressure is equal to preset pressure of 12 mm Hg, that means gas is not going in free abdominal cavity, it may be in preperitoneal space or inside omentum or may be in bowel. If gas is flown >5 L without any distention of abdomen that may be due to leakage or gas may be going inside the vessel. Hanging Drop Test 81
A B Figs. 20A and B: Quadromanometric indicators. Flow rate: This reflects the rate of flow of CO2 through the tubing of insufflator. When Veress needle is attached, the flow rate should be adjusted to 1 L/min. Studies were performed over animal in which direct intravenous (IV) CO2 were administered, and it was found that risk of air embolism is less if rate is within 1 L/min. At the time of access using Veress needle technique, sometime Veress needle may inadvertently enter inside a vessel but if the flow rate is 1 L/min there is a less chance of serious complication. When initial pneumoperitoneum is achieved and cannula is inside abdominal cavity, the insufflators flow rate may be set at maximum, to compensate loss of CO2 due to use of suction irrigation instrument. This should be remembered that if insufflator is set to its maximum flow rate then also it will allow flow only if the actual pressure is less than preset pressure otherwise it will not pump any gas. Most of the surgeons keep initial flow rate with Veress needle to 1 L/min and as soon as they confirm that gas is going satisfactorily inside the abdominal cavity by percussion examination and seeing obliteration of liver dullness (Fig. 21), then they increase flow rate to 3 L/min. No matter how much flow rate you set for Veress needle, the eye of normal caliber Veress needle can give away CO2 flow at maximum 2.5 L/min. Once cannula is in place flow rate can be increase but when the flow of CO2 is >10 L/min inside the abdominal cavity through cannula and there is leak, there is always a risk of hypothermia and dryness of intestine. To avoid this hypothermia in all modern microprocessor controlled Laproflattor, there is an electronic heating system which maintains the temperature of CO2. Total gas used: As soon as 100–200 mL of gas is inside the abdominal cavity, surgeon should do percussion of the right hypochondrium and liver dullness should obliterate with tympanic sound (Fig. 21). This is the fourth indicator of insufflator. Normal size human abdominal cavity needs 1.5-L CO2 to achieve intra-abdominal actual pressure of 12 mm Hg. In some big size abdominal cavity and in Fig. 21: Tapping over right hypochondrium will demonstrate obliteration of liver dullness. multipara patients, sometimes we need 3 L of CO2 (rarely 5–6 L) to get desired pressure of 12 mm Hg. Whenever there is less or more amount of gas used to inflate a normal abdominal cavity, surgeon should suspect some errors in pneumoperitoneum technique. These errors may be leakage or may be preperitoneal space creation or extravasation of gas. PRIMARY TROCAR INSERTION Technical errors in the insertion of trocars after creation of pneumoperitoneum are the most common causes of injury, resulting from inadequate stabilization of the abdominal wall, excessive resistance to trocar insertion, and excessive, misdirected or uncontrolled force applied by the surgeon along the axis of the trocar. It is important to stabilize the abdominal wall by full insufflation, complete muscle relaxation, to increase the distance between the anterior abdominal wall and the retroperitoneal vessels and the abdominal organs. It is important to ensure that the skin incision is of enough length and that the reusable trocar tip is sharp so that no resistance is offered. 83
SECTION 1: Essentials of Laparoscopy Trocar and cannula design currently available have several basic features in common. They come in a variety of sizes and the central trocar may have a pyramidal, conical or rounded tip (Figs. 22 and 23). They have a valve system and a gas input with a tap. These cannulas have flap, bicuspid or magnetic valves and care should be taken when passing telescope through the port that lens of telescope should not hit the valve otherwise it can be damaged. Some disposable cannula has a safety system with a cylinder jumps forward after penetration of abdominal wall and forms a shield over the sharp trocar tip. This is not fool proof due to shield lag. In the most recent disposable cannula, the trocar itself is spring loaded. Few optical trocars are also available which has been discussed in Chapter 3: Laparoscopic Equipment and Instrument. The first trocar and cannula inserted is usually 11 mm in diameter. This will accommodate a 10-mm telescope and leave enough space in the cannula for rapid gas insufflation, if required. Steps of Primary Trocar Insertion Patient Position As for Veress needle insertion, patient should be placed supine with 10–20° head down. The cephalocaudal relationship between the aortic bifurcation and the umbilicus has been studied radiologically. The umbilicus is often located directly above or cephalad to the aortic bifurcation and is consistently located cephalad to where the left common iliac vein crosses the midline. The aortic bifurcation is located more caudal to the umbilicus in the Trendelenburg’s position than in the supine position. Site The same site of Veress needle entry should be used for primary trocar insertion. Inferior or superior crease of umbilicus can be used in average built patient and transumbilical Fig. 22: Reusable trocar and cannula. incision can be used in obese patient. Before introduction of trocar, surgeon should confirm pneumoperitoneum. After adequate distention of abdominal cavity, the actual pressure should be equal to the preset pressure and gas flow should be stopped. Before introduction of trocar, the initial 2-mm stab puncture wound of skin for Veress needle should be extended to 11 mm (Fig. 24). It should be remembered that most common cause of forceful entry inside the abdominal cavity with primary trocar is small skin incision. To avoid inadvertent injury of bowel due to forceful uncontrolled entry, the incision of skin should not be <11 mm in size. The skin incision for trocar should be smiling in shape (U-shaped) along the crease of umbilicus to get a better cosmetic value. After giving 11-mm incision with 11 number blades, surgeon should spread fatty tissues with Kelly clamp or mosquito forceps (Fig. 25). This will also dilate the obliterated vitellointestinal duct which was demonstrated first time by Scandinavian surgeons so it is called Scandinavian technique. Introduction of Primary Trocar Surgeon should hold the trocar in proper way. Head of trocar should rest on thenar eminence, middle finger should encircle air inlet and index finger should point toward sharp end (Fig. 26). After holding the trocar properly in hand, full thickness of abdominal wall should be lifted by fingers thenar and hypothenar muscles. After creation of pneumoperitoneum, lifting of abdominal wall is difficult because it slips. To overcome this, it should be grasped to counter the pressure exerted by the tip of trocar. Angle of Insertion Initially, angle of insertion for primary trocar should be perpendicular to abdominal wall but once surgeon feels Fig. 23: Disposable trocar and cannula.
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