489
Aust. N . Z . J . Surg. 1992,62,489-491
SURGICAL TECHNIQUE A SAFE, NEW APPROACH TO ESTABLISHING A PNEUMOPERITONEUM AT LAPAROSCOPY A . KARATASSAS,* D. WALSH,*AND D. W. HAMILTON+ Departments of Surgery,
* The Queen Elizabeth Hospital, and
Modbury Hospital, Adelaide,
South Australia, Australia The traditional method of establishing a pneumoperitoneum before laparoscopic surgery is via a Verres needle inserted in the midline below the umbilicus while tenting the abdominal wall with the hand. A new approach is described in which preliminary surgical exposure and tenting of the linea alba immediately above the umbilicus is achieved before needle insertion through the superior margin of the umbilical ring. The advantages of this new technique over the conventional method are discussed. Further technical features important in the safe formation of the pneumoperitoneum are emphasized.
Key words: laparoscopic cholecystectomy, laparoscopic procedures, pneumoperitoneum,supra-umbilical approach, Verres needle.
Introduction Laparoscopic abdominal surgical procedures have become frequent with the introduction of laparoscopic cholecystectomy. Use of laparoscopic instruments calls for the creation of a preliminary pneumoperitoneum which is achieved by the blind introduction of a fine calibre Verres needle just below the umbilicus, into the peritoneal cavity. Correct placement of the needle may be difficult in the obese patient when it may fail to penetrate into the peritoneal cavity and in any patient the procedure carries the risk of injury to intra-abdominal structures. A new technique for the placement of the pneumoperitoneum needle potentially reduces the risks associated with other techniques and has been found to be satisfactory in a preliminary series of 60 patients.
'
Anatomy of the umbilicus The anatomical structure of the umbilicus consists of a ring of fibrotic tissue within the linea alba to which the skin is attached directly. On its inner aspect, four ligaments are attached to the fibrotic umbilical ring. They are the ligament teres above and the median and two lateral liga-
Correspondence: Dr A. Karatassas, The Queen Elizabeth Hospital, 28 Wocdville Road, Wocdville South, SA 501 I , Australia. Accepted for publication 21 November 1991
lz \c
Skin hook
Needle
Subcutaneous fat
Fig. 1. Diagrammatic, sagittal view of the Verres needle insertion using the hook retractors to elevate the linea alba.
ments below, all of which converge onto the inferior margin of the ring and form a fibrous nodule. Deep to this fibro-ligamental layer lies a thickening of the fascia transversalis known as Rickets fascia to which the peritoneum is firmly attached at a level where the preperitoneal fat is sparse (Fig 1).*
Technique The procedure is performed in the Trendelenburg position under general anaesthesia after catheterizing the bladder and decompressing the stomach. A 15 mm transverse skin incision is made directly above the umbilicus. A haemostat is introduced and the tissue is spread, to expose the linea alba. A pair of strong, two-pronged hook retractors or Allis
490
KARATASSAS E T A L .
clamps are introduced into the incision and attached to the linea alba which is then elevated forcibly. The needle is then passed between these hooks, through the superior edge of the umbilical ring, at a point which can be palpated at the junction of the umbilical cicatrix and the linea alba (Fig. 1). In the obese patient, palpation of this junction is facilitated by the application of a skin hook to the umbilical cicatrix to render it taut. This manoeuvre also assists in elevating the linea alba. The needle is best held between the thumb and forefinger with the wrist stabilized on the abdominal wall so that a steady and controlled entry is achieved. It is important that the needle is held away from the hub so as not to hinder the spring action of the tip and that it is inserted in a caudal direction at 45 degrees so that it points inferior to the bifurcation of the aorta and the junction of the iliac veins. The needle is inserted for a short distance of 2-4cm before a sudden loss of resistance occurs indicating that the needle has passed into the pentoneal cavity. Even in the obese patient this distance does not usually exceed 4 cm. The intraperitoneal position of the needle is confirmed by a series of tests. The needle is initially aspirated to exclude the presence of blood or intestinal contents and then 20mL of normal saline is injected. The saline cannot be aspirated. On removal of the syringe, saline within the needle is sucked into the peritoneal cavity with respiration. The needle is then connected to the insufflator, and the early, intra-abdominal, insufflation pressure should be less than 10mmHg. Finally, tympany over the liver is noted on percussion, with the introduction of only 400 mL of carbon dioxide. Once the intraperitoneal position has been confirmed, 2-4L of carbon dioxide are introduced at a low flow rate of 1 L/min. A lOmm trocar and cannula with safety shield (Autosuture, Ethicon) is then inserted in the same position and direction as the needle. The safety shield is engaged once the trocar is through the peritoneum.
the umbilicus from previous midline incisions. No major complications were encountered following insertion of the Verres needle or trocar and cannula, with no episodes of extraperitoneal insufflation. Leakage of carbon dioxide around the 10 mm cannula was minimal and did not pose any difficulties during the procedures. No patients suffered wound infections, but five developed minor bruising around the umbilicus postoperatively.
Discussion Successfully establishing the pneumoperitoneum before trocar entry is the first step in laparoscopy. This procedure may be associated with morbidity or mortality. Chamberlain et al. reported an incidence of direct trauma to the urinary tract of l/SOOO, to bowel of 11550, to bowel mesentery of 1/900 and to the pelvic side wall of 1/1 The traditional technique for pneumoperitoneum involves the insertion of the needle in an infraumbilical position after the lower abdominal wall has been grasped and elevated in the midline below the umbilicus. This method has several disadvantages. First, in the obese patient it may be difficult to grasp and elevate the lower abdominal wall, and when achieved leads to tenting of the skin and subcutaneous tissue without corresponding tenting of the linea alba and peritoneum away from the internal structures (Fig. 2). The authors have confirmed this in a series of five patients, by intra-operative ultrasound imaging (Acuson 128XP/10 with 5 MHz linear array probe) of the anterior abdominal wall while performing this manoeuvre. Second, the tenting of the subcutaneous tissue creates a longer course for the needle before entering the peritoneal cavity. Third, the needle may penetrate the peritoneum well below the umbilicus where the separate abdominal layers are loosely interposed and where there is an abundance of preperitoneal fat in the midline, increasing the possibility of extraperitoneal insufflation.
Results This technique was performed on 60 patients, 50 of whom underwent laparoscopic cholecystectomy and the remainder diagnostic laparoscopy . These patients (45 male, 15 female) had a mean age of 40 years (range 15-80 years) and mean weight of 72kg (range 50-109kg). At least 50% of these patients were obese based on the body mass index scale.3 Previous abdominal surgery had been performed on 25 of these patients; these included gynaecological surgery (hysterectomy, Caesarian section and tuba1 ligation; n = 15) and appendicectomy ( n = 8). Only three patients had scars extending to
Fig. 2. Diagrammatic, sagittal view of Verres needle insertion using the conventional technique.
49 1
NEW APPROACH TO PNEUMOPERITONEUM
The new technique described offers several advantages over the more traditional approach. The hook retractors allow the linea alba and adjacent peritoneum to be elevated further than with the conventional technique, especially in the obese patient. Also, the course of the needle is significantly shortened. These two factors are important in reducing the risk of damage to internal structures. Additionally, the possibility of needle malposition is decreased since the peritoneum is usually firmly attached to the overlying fascia1 layer at the level of the umbilical ring. Finally, needle positioning is facilitated and made more accurate with the use of a two hook technique which creates a plateau of tissue as opposed to the tent-like elevation achieved by the single hook method (Fig. 3). In performing the procedure, the authors have found the sharp, brisk spring-action of the disposable needle (Auto Suture, Surgineedle) to be preferable to the stainless steel reusable type, which becomes dull and impaired with repeated use. Confirming the intraperitoneal position of the needle tip is important and several safe methods are available. However, many surgeons prefer to confirm the intraperitoneal position by free movement of the needle tip. This technique may be unsafe as movement of the needle within the abdominal cavity may inadvertently cause damage to internal structures, particularly if intestine or major vascular structures have been initially entered. The trocar and cannula with safety shield is routinely used. The rapid activation of the safety shield over the sharp edge of the trocar, once it has entered the peritoneal cavity, prevents damage to the abdominal organs. Other methods have recently been described in establishing a pneumoperitoneum including an open direct trocar in~ertion,'.~ direct perpendicular puncture through the centre of the umbilicus" and insertion of the needle over the left McBurney's point with no attempt made to tent up the abdominal wall.
'
Skin
Subculaneour fat
Rectus muscle Linea alba Preperltoneal la! Perll0"eYm
Fig. 3. Diagrammatic coronal view showing the plateau between hooks facilitating needle insertion.
In patients with suspected adhesions around the umbilicus from previous surgery, the open technique is the preferred option in establishing a pneumoperitoneum. This technique involves a cutdown into the peritoneal cavity without the use of a Verres needle. A purse-string or stay sutures are placed in the fascia and a standard or modified cannula is directly inserted into the peritoneal cavity under vision. Insufflation is then c om rne n~e d.~ This open technique is time consuming, requires larger skin incisions and sometimes a considerable amount of dissection. Hence it is used in selected cases where adhesions around the umbilicus are likely to be encountered (e.g. midline incisions). The authors have used the new technique in over 60 cases and have found it to be a simple method of establishing a pneumoperitoneum without complication. The simplicity and safety of this technique make it a recommended one for the surgeon in training.
Acknowledgement The authors wish to express their sincere appreciation to Prof. R. E. Elmslie for critically reviewing the manuscript.
References I . REODICK E. J. & OLSEND. 0. (1989) Laparoscopic laser cholecystectomy. Surg. Endosc. 3, 131-3. H. (1973) Surgical anatomy of 2. ORDAR. & NATHAN the umbilical structures. In?. Surg. 58, 458-64. 3. PORESW. J. (1986) Surgical approach to morbid obesity. In: The Biological Basis of Modern Surgical Practice, 13th edn (Ed. J. Sabiston), Chapter V, p. 929. W. B. Saunders Company, Philadelphia. 4. CHAMBERLAIN G. & BRAUN J. D. (Eds) (1978) Gynaecological Laparoscopy: Report on the Confidential Enquiry into Gynaecological Laparoscopy . Royal College of Obstetricians and Gynaecologists, England. 5. HASSONH. M. (1971) Modified instrument and method for laparoscopy . Am. J . Obstet. Gynecol. 110, 886-7. 6. SURS . (1985) Modified method of open laparoscopy. J . Reprod. Med. 30, 421-6. 7. FITZGIBBONS R. J . JR, SALERNO G . M. & FILIPIC. .I. (1991) Open laparoscopy. In: Surgical Laparoscopy, 1st edn (Ed. K . A . Zucker). Quality Medical Publishing Inc., Missouri. J . F. (1983) Direct 8. COPELAND C . , WINGR.'& HULKA trocar insertion at laparoscopy: An evaluation. Obstet. Gynecol. 62, 655-9. 9. BYRON J. W., FUJIYOSHI C. A . & MIYAZAWA K. (1989) Evaluation of direct trocar insertion technique at laparoscopy. Obstet. Gynaecol. 74, 423-5. 10. TOTHA . & GRAFM. (1984) The center of the umbilicus as the Veres needle's entry site for laparoscopy. J . Reprod. Med. 29, 126-8. 1 I . UDWAOIA T. E. (1986) Peritoneoscopy for Surgeons. Ann. R . Coll. Surg. Engl. 68, 125-9.
Aust. N . Z . J . Surg. 1992,62,489-491
SURGICAL TECHNIQUE A SAFE, NEW APPROACH TO ESTABLISHING A PNEUMOPERITONEUM AT LAPAROSCOPY A . KARATASSAS,* D. WALSH,*AND D. W. HAMILTON+ Departments of Surgery,
* The Queen Elizabeth Hospital, and
Modbury Hospital, Adelaide,
South Australia, Australia The traditional method of establishing a pneumoperitoneum before laparoscopic surgery is via a Verres needle inserted in the midline below the umbilicus while tenting the abdominal wall with the hand. A new approach is described in which preliminary surgical exposure and tenting of the linea alba immediately above the umbilicus is achieved before needle insertion through the superior margin of the umbilical ring. The advantages of this new technique over the conventional method are discussed. Further technical features important in the safe formation of the pneumoperitoneum are emphasized.
Key words: laparoscopic cholecystectomy, laparoscopic procedures, pneumoperitoneum,supra-umbilical approach, Verres needle.
Introduction Laparoscopic abdominal surgical procedures have become frequent with the introduction of laparoscopic cholecystectomy. Use of laparoscopic instruments calls for the creation of a preliminary pneumoperitoneum which is achieved by the blind introduction of a fine calibre Verres needle just below the umbilicus, into the peritoneal cavity. Correct placement of the needle may be difficult in the obese patient when it may fail to penetrate into the peritoneal cavity and in any patient the procedure carries the risk of injury to intra-abdominal structures. A new technique for the placement of the pneumoperitoneum needle potentially reduces the risks associated with other techniques and has been found to be satisfactory in a preliminary series of 60 patients.
'
Anatomy of the umbilicus The anatomical structure of the umbilicus consists of a ring of fibrotic tissue within the linea alba to which the skin is attached directly. On its inner aspect, four ligaments are attached to the fibrotic umbilical ring. They are the ligament teres above and the median and two lateral liga-
Correspondence: Dr A. Karatassas, The Queen Elizabeth Hospital, 28 Wocdville Road, Wocdville South, SA 501 I , Australia. Accepted for publication 21 November 1991
lz \c
Skin hook
Needle
Subcutaneous fat
Fig. 1. Diagrammatic, sagittal view of the Verres needle insertion using the hook retractors to elevate the linea alba.
ments below, all of which converge onto the inferior margin of the ring and form a fibrous nodule. Deep to this fibro-ligamental layer lies a thickening of the fascia transversalis known as Rickets fascia to which the peritoneum is firmly attached at a level where the preperitoneal fat is sparse (Fig 1).*
Technique The procedure is performed in the Trendelenburg position under general anaesthesia after catheterizing the bladder and decompressing the stomach. A 15 mm transverse skin incision is made directly above the umbilicus. A haemostat is introduced and the tissue is spread, to expose the linea alba. A pair of strong, two-pronged hook retractors or Allis
490
KARATASSAS E T A L .
clamps are introduced into the incision and attached to the linea alba which is then elevated forcibly. The needle is then passed between these hooks, through the superior edge of the umbilical ring, at a point which can be palpated at the junction of the umbilical cicatrix and the linea alba (Fig. 1). In the obese patient, palpation of this junction is facilitated by the application of a skin hook to the umbilical cicatrix to render it taut. This manoeuvre also assists in elevating the linea alba. The needle is best held between the thumb and forefinger with the wrist stabilized on the abdominal wall so that a steady and controlled entry is achieved. It is important that the needle is held away from the hub so as not to hinder the spring action of the tip and that it is inserted in a caudal direction at 45 degrees so that it points inferior to the bifurcation of the aorta and the junction of the iliac veins. The needle is inserted for a short distance of 2-4cm before a sudden loss of resistance occurs indicating that the needle has passed into the pentoneal cavity. Even in the obese patient this distance does not usually exceed 4 cm. The intraperitoneal position of the needle is confirmed by a series of tests. The needle is initially aspirated to exclude the presence of blood or intestinal contents and then 20mL of normal saline is injected. The saline cannot be aspirated. On removal of the syringe, saline within the needle is sucked into the peritoneal cavity with respiration. The needle is then connected to the insufflator, and the early, intra-abdominal, insufflation pressure should be less than 10mmHg. Finally, tympany over the liver is noted on percussion, with the introduction of only 400 mL of carbon dioxide. Once the intraperitoneal position has been confirmed, 2-4L of carbon dioxide are introduced at a low flow rate of 1 L/min. A lOmm trocar and cannula with safety shield (Autosuture, Ethicon) is then inserted in the same position and direction as the needle. The safety shield is engaged once the trocar is through the peritoneum.
the umbilicus from previous midline incisions. No major complications were encountered following insertion of the Verres needle or trocar and cannula, with no episodes of extraperitoneal insufflation. Leakage of carbon dioxide around the 10 mm cannula was minimal and did not pose any difficulties during the procedures. No patients suffered wound infections, but five developed minor bruising around the umbilicus postoperatively.
Discussion Successfully establishing the pneumoperitoneum before trocar entry is the first step in laparoscopy. This procedure may be associated with morbidity or mortality. Chamberlain et al. reported an incidence of direct trauma to the urinary tract of l/SOOO, to bowel of 11550, to bowel mesentery of 1/900 and to the pelvic side wall of 1/1 The traditional technique for pneumoperitoneum involves the insertion of the needle in an infraumbilical position after the lower abdominal wall has been grasped and elevated in the midline below the umbilicus. This method has several disadvantages. First, in the obese patient it may be difficult to grasp and elevate the lower abdominal wall, and when achieved leads to tenting of the skin and subcutaneous tissue without corresponding tenting of the linea alba and peritoneum away from the internal structures (Fig. 2). The authors have confirmed this in a series of five patients, by intra-operative ultrasound imaging (Acuson 128XP/10 with 5 MHz linear array probe) of the anterior abdominal wall while performing this manoeuvre. Second, the tenting of the subcutaneous tissue creates a longer course for the needle before entering the peritoneal cavity. Third, the needle may penetrate the peritoneum well below the umbilicus where the separate abdominal layers are loosely interposed and where there is an abundance of preperitoneal fat in the midline, increasing the possibility of extraperitoneal insufflation.
Results This technique was performed on 60 patients, 50 of whom underwent laparoscopic cholecystectomy and the remainder diagnostic laparoscopy . These patients (45 male, 15 female) had a mean age of 40 years (range 15-80 years) and mean weight of 72kg (range 50-109kg). At least 50% of these patients were obese based on the body mass index scale.3 Previous abdominal surgery had been performed on 25 of these patients; these included gynaecological surgery (hysterectomy, Caesarian section and tuba1 ligation; n = 15) and appendicectomy ( n = 8). Only three patients had scars extending to
Fig. 2. Diagrammatic, sagittal view of Verres needle insertion using the conventional technique.
49 1
NEW APPROACH TO PNEUMOPERITONEUM
The new technique described offers several advantages over the more traditional approach. The hook retractors allow the linea alba and adjacent peritoneum to be elevated further than with the conventional technique, especially in the obese patient. Also, the course of the needle is significantly shortened. These two factors are important in reducing the risk of damage to internal structures. Additionally, the possibility of needle malposition is decreased since the peritoneum is usually firmly attached to the overlying fascia1 layer at the level of the umbilical ring. Finally, needle positioning is facilitated and made more accurate with the use of a two hook technique which creates a plateau of tissue as opposed to the tent-like elevation achieved by the single hook method (Fig. 3). In performing the procedure, the authors have found the sharp, brisk spring-action of the disposable needle (Auto Suture, Surgineedle) to be preferable to the stainless steel reusable type, which becomes dull and impaired with repeated use. Confirming the intraperitoneal position of the needle tip is important and several safe methods are available. However, many surgeons prefer to confirm the intraperitoneal position by free movement of the needle tip. This technique may be unsafe as movement of the needle within the abdominal cavity may inadvertently cause damage to internal structures, particularly if intestine or major vascular structures have been initially entered. The trocar and cannula with safety shield is routinely used. The rapid activation of the safety shield over the sharp edge of the trocar, once it has entered the peritoneal cavity, prevents damage to the abdominal organs. Other methods have recently been described in establishing a pneumoperitoneum including an open direct trocar in~ertion,'.~ direct perpendicular puncture through the centre of the umbilicus" and insertion of the needle over the left McBurney's point with no attempt made to tent up the abdominal wall.
'
Skin
Subculaneour fat
Rectus muscle Linea alba Preperltoneal la! Perll0"eYm
Fig. 3. Diagrammatic coronal view showing the plateau between hooks facilitating needle insertion.
In patients with suspected adhesions around the umbilicus from previous surgery, the open technique is the preferred option in establishing a pneumoperitoneum. This technique involves a cutdown into the peritoneal cavity without the use of a Verres needle. A purse-string or stay sutures are placed in the fascia and a standard or modified cannula is directly inserted into the peritoneal cavity under vision. Insufflation is then c om rne n~e d.~ This open technique is time consuming, requires larger skin incisions and sometimes a considerable amount of dissection. Hence it is used in selected cases where adhesions around the umbilicus are likely to be encountered (e.g. midline incisions). The authors have used the new technique in over 60 cases and have found it to be a simple method of establishing a pneumoperitoneum without complication. The simplicity and safety of this technique make it a recommended one for the surgeon in training.
Acknowledgement The authors wish to express their sincere appreciation to Prof. R. E. Elmslie for critically reviewing the manuscript.
References I . REODICK E. J. & OLSEND. 0. (1989) Laparoscopic laser cholecystectomy. Surg. Endosc. 3, 131-3. H. (1973) Surgical anatomy of 2. ORDAR. & NATHAN the umbilical structures. In?. Surg. 58, 458-64. 3. PORESW. J. (1986) Surgical approach to morbid obesity. In: The Biological Basis of Modern Surgical Practice, 13th edn (Ed. J. Sabiston), Chapter V, p. 929. W. B. Saunders Company, Philadelphia. 4. CHAMBERLAIN G. & BRAUN J. D. (Eds) (1978) Gynaecological Laparoscopy: Report on the Confidential Enquiry into Gynaecological Laparoscopy . Royal College of Obstetricians and Gynaecologists, England. 5. HASSONH. M. (1971) Modified instrument and method for laparoscopy . Am. J . Obstet. Gynecol. 110, 886-7. 6. SURS . (1985) Modified method of open laparoscopy. J . Reprod. Med. 30, 421-6. 7. FITZGIBBONS R. J . JR, SALERNO G . M. & FILIPIC. .I. (1991) Open laparoscopy. In: Surgical Laparoscopy, 1st edn (Ed. K . A . Zucker). Quality Medical Publishing Inc., Missouri. J . F. (1983) Direct 8. COPELAND C . , WINGR.'& HULKA trocar insertion at laparoscopy: An evaluation. Obstet. Gynecol. 62, 655-9. 9. BYRON J. W., FUJIYOSHI C. A . & MIYAZAWA K. (1989) Evaluation of direct trocar insertion technique at laparoscopy. Obstet. Gynaecol. 74, 423-5. 10. TOTHA . & GRAFM. (1984) The center of the umbilicus as the Veres needle's entry site for laparoscopy. J . Reprod. Med. 29, 126-8. 1 I . UDWAOIA T. E. (1986) Peritoneoscopy for Surgeons. Ann. R . Coll. Surg. Engl. 68, 125-9.
