Left Upper Quadrant Called Safe Alternative for Umbilicus Entry


SAN FRANCISCO — The ninth intercostal space in the left upper quadrant provides a safe alternative to umbilicus entry for laparoscopy when the patient has adhesions, Neena Agarwala, M.D., reported in a poster presentation during the annual meeting of the American Association of Gynecologic Laparoscopists.

In a large retrospective study, Dr. Agarwala of the University of Nebraska Medical Center, Omaha, studied all 918 laparoscopies performed over a 6-year period on patients with surgical scars at a university hospital and a community hospital. Of those 918 laparoscopies, 504 (55%) of the patients had umbilical adhesions.

Using the alternate entry position in the left upper quadrant resulted in no trocar-related injuries and only two Veress needle-related injuries.

One was a needle puncture to the left lung margin resulting in transient pneumothorax, and the other was a Veress needle placement in the stomach, which was recognized and repaired immediately.

Extensive adhesion lysis resulted in two bowel injuries that required additional surgery via laparotomy.

The left upper quadrant technique involves the insertion of the Veress needle parallel to the anterior thoracic wall. The needle's course goes along the interior aspect of the ninth rib.

The curvature of the rib together with the rigidity of the peritoneum in this area provides a protected space free of all intraabdominal organs, Dr. Agarwala said.

The umbilical adhesions in these patients resulted from one of three causes. Of the 504 patients with adhesions, 62% had a prior abdominal wall incision, 22% had a prior Pfannenstiel incision, and 16% had a prior laparoscopic incision.

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