Ensuring Safe Laparoscopic Access

In laparoscopic surgery, the most damage may occur during entry. Fortunately, such damage is almost totally avoidable if you use the proper techniques, a well-thought-out point of entry, and the safest equipment available.

I know laparoscopic surgeons who use a blind, primary trocar entry technique using no insufflation. They can all recount the number of cases they've done without a major adverse event; one surgeon proudly told me he “put a little nick in the common iliac artery with an accessory port” and solved the problem with rapid action and a quick stitch.

My response is that these surgeons have either been very lucky or simply haven't done enough procedures for the inevitable disasters to catch up with them. I am absolutely opposed to blindly putting large spikes into the abdomen, and I think doing so is an approach that should be condemned.

As laparoscopic surgeons, we generally operate on young, healthy patients, sometimes for elective reasons. The potential for tragedy here is great, and it makes no sense to risk lives and great bodily injury when safe and predictable alternatives are available. I conceptualize safe access by breaking it down into three precise goals:

▸ Avoiding damage to the anterior abdominal wall.

▸ Avoiding intraabdominal structures.

▸ Avoiding retroperitoneal structures. These goals are accomplished by using the most appropriate instruments available, such as a dilating trocar and adjunctive 2-mm laparoscope; choosing the optimal entry site; and properly insufflating the abdomen.

Anterior wall tissue damage can be greatly minimized by using expanding trocars that stretch the tissue rather than cut it. Many companies make disposable dilating trocars.

The reusable radially expanding system from Tyco has a sleeve that is passed into the abdominal cavity over a Veress needle; it is dilated solely with lateral pressure or force. No downward force is applied to the patient's abdomen.

When the tissue is stretched, less damage is done, less pain is caused, recovery is quicker, and the long-term risk of hernia formation is lower.

Avoiding intraabdominal structures is a matter of entry location. I agree with Dr. Palter that the thinnest tissue underlies the umbilicus, and that's where I like to place my primary port. But unfortunately, major vessels—and often adhesions—also directly underlie this spot. It's the place where laparoscopic entry is most likely to kill a patient, and I enter it only under direct visualization.

Several studies have assessed the rate of abdominal adhesions in patients who have had previous surgery. In a 1997 study, none of 45 patients had adhesions after laparoscopy, 17 of 29 had adhesions after a midvertical incision, and 11 of 39 had adhesions after a low transverse incision (J. Am. Assoc. Gynecol. Laparosc. 1997;4:353–6).

French gynecologic surgeon Alain Audebert, M.D., described adhesions in 331 patients with prior surgery. Adhesions were present in half of patients with a prior midline incision, in 21% with a lower transverse incision, and 1.8% of patients with prior laparoscopic surgery had adhesions. Even among 440 patients with no prior surgery, the rate of adhesions was 0.6%.

In a recent study of 100 of my own patients, I found adhesion formation in 16 of 36 who had midline incisions, 20 of 45 who had transverse incisions, and 7 of 19 who had other incisions.

Although it's rare, I recently operated on a patient whose only previous surgery was laparoscopic and even she had an adhesion directly under the umbilicus.

On the other hand, it is extremely rare for surgical adhesions to form over the left upper quadrant of the abdomen, because the gallbladder and appendix lie on the other side. Only trauma surgery or splenectomies are likely to result in adhesions at this anatomical location, which was first described as an entry site by Raoul Palmer, M.D., in 1972. Furthermore, although central obesity can complicate initial access at the umbilicus, the lower margin of the rib cage in the midclavicular line almost always can be palpated, providing a landmark structure for entry at this site.

It is for all these reasons that I favor a left upper quadrant entry—not just in special cases, as Dr. Palter suggested, but as a matter of routine. I have performed approximately 500 laparoscopic procedures using this approach; Dr. Audebert has performed more than 2,000.

Patients receive a nasogastric tube so that their stomachs can be emptied before the procedure to reduce the chance of this underlying organ being damaged, although a needle injury to the stomach or liver is not a major complication.

Splenomegaly is a contraindication.