Reroute Laparoscopic Entry in Select Patients : Subumbilical adhesions from previous surgeries are a major cause of complications and visceral injury.


LONDON — Physicians attempting laparoscopic entry in patients who have had previous abdominal surgery should consider an alternative to the traditional umbilical entry port, recommended Colin Davis, M.D., associate clinical director of gynecology at St. Bartholomew's Hospital.

Subumbilical adhesions from previous surgeries are a major cause of laparoscopic entry-related complications and can lead to visceral injury secondary to Veress needle or trocar insertion, he said at the annual congress of the International Society for Gynecologic Endoscopy.

“This is an uncommon, but serious complication of laparoscopic surgery and a major cause of [medicolegal] claims,” he said, adding that the Palmer's point entry in the left upper quadrant avoids blind entry in the umbilicus—the area most likely to contain adhesions from previous surgery.

“We should all become familiar with an alternative entry point for patients with a history of previous abdominal surgery,” he said, specifying that this would include patients who've had one previous Pfannenstiel, suprapubic, transverse, or midline laparotomy.

This approach also should be considered in patients who are overweight and in patients with whom entry through the umbilicus is difficult, he said.

Dr. Davis' group assessed the prevalence of subumbilical adhesions in a prospective study of 96 women undergoing Palmer's point entry procedures.

Subumbilical adhesions were seen in 57% of those with a history of one Pfannenstiel laparotomy and 66% among those who'd had two previous Pfannenstiels. Women with a previous midline incision had a 92% risk of subumbilical adhesions.

Overall, 32% of adhesions contained bowel, he reported. There were no subumbilical adhesions in women who were considered low risk for adhesions but who underwent Palmer's point entry due to difficult initial insufflation, large ovarian cysts extending to the umbilicus, or patient preference to avoid an umbilical scar.

According to Dr. Davis, Palmer's point entry is well described, but it is not routinely used in high-risk patients, even though it is easy to learn.

To perform the entry, a Veress needle is introduced 3 cm below the subcostal line on the left, and the peritoneal cavity is insufflated.

Then a 5-mm trocar is introduced, followed by the laparoscope, and the secondary points are then made under direct vision.

“The main disadvantage is a slightly altered perspective of the pelvis because you are looking at it from a different angle,” he said.

In addition, physicians should be prepared to have to push slightly further to gain entry into the peritoneal cavity, since the tissue is slightly thicker than it is at the umbilicus.

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