RCOG greentop guideline

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    RCOG greentop guideline:
    7.1 Veress needle (closed) laparoscopic entry technique
    How should the closed laparoscopic entry technique be performed?
    In most circumstances the primary incision for laparoscopy should be vertical from the base of the umbilicus (not in the skin below the umbilicus). Care should be taken not to incise so deeply as to enter the peritoneal cavity. The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria. The operating table should be horizontal (not in the Trendelenburg tilt) at the start of the procedure. The abdomen should be palpated to check for any masses and for the position of the aorta before insertion of the Veress needle. The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at right angles to the skin and should be pushed in just sufficiently to penetrate the fascia and the peritoneum. Two audible ? are usually heard as these layers are penetrated. Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel or vessel into a more complex tear.

    What intra-abdominal pressure should be achieved to safely insert the primary trocar?
    An intra-abdominal pressure of 20–25 mmHg should be used for gas insufflation before inserting the primary trocar.
    The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete. This gives adequate distension for operative laparoscopy and allows the anaesthetist to ventilate the patient safely and effectively.

    Where should the primary trocar be inserted ?
    The primary trocar should be inserted in a controlled manner at 90 degrees to the skin, through the incision at the thinnest part of the abdominal wall, in the base of the umbilicus. Insertion should be stopped immediately the trocar is inside the abdominal cavity. Once the laparoscope has been introduced through the primary cannula, it should be rotated through
    360 degrees to check visually for any adherent bowel. If this is present, it should be closely inspected for any evidence of haemorrhage, damage or retroperitoneal haematoma. If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site should be visualised from a secondary port site, preferably with a 5-mm laparoscope. On completion of the procedure, the laparoscope should be used to check that there has not been a through-and-through injury of bowel adherent under the umbilicus by visual control during removal.

    7.2 Hasson (open) entry technique
    How should the open entry technique be performed?
    When the Hasson open laparoscopic entry is employed, confirmation that the peritoneum has been
    opened should be made by visualising bowel or omentum before inserting the blunt tipped cannula.
    The Hasson technique of open laparoscopic entry is an alternative to closed laparoscopy that avoids the use of
    sharp instruments after the initial skin incision. It allows the insertion of a blunt-ended trocar under direct vision.
    Once the fascial edges are incised, they should be held by a lateral stay suture on either side of the
    incision. Once the peritoneum is opened, the fascial sutures are then pulled firmly into the suture
    holders on the cannula to produce an airtight seal with the cone of the cannula. Gas is insufflated
    directly through the cannula to produce the pneumoperitoneum. The blunt trocar is withdrawn
    only after the abdomen is partially distended. At the end of the procedure, the fascial defect should
    be closed using the stay sutures (and possibly additional sutures) to minimise the risk of herniation.

    8. Alternative entry techniques
    What alternative entry techniques are available?

    8.1 Direct trocar insertion
    Direct trocar insertion is an acceptable alternative trocar insertion method.
    This technique was developed to overcome the difficulty associated with grasping the abdominal
    wall already distended by the pneumoperitoneum.25 Although in experienced hands it is the most
    rapid method of entry and can be safely used if the cases are carefully selected, it is not widely used
    within gynaecological practice. Six randomised controlled trials have compared Veress needle with
    direct trocar entry.19,26–30 Meta-analysis does not show any safety disadvantage from using direct
    entry in terms of major complications. There may be an advantage when considering minor
    complications.20

    8.2 Alternative entry devices
    There are several ingenious devices that have been introduced during the last decade to try to minimise the
    risk during primary trocar insertion. These include visual access systems,31 radially expanding trocars32 and
    second-generation Endotip® (Karl Storz, Tutlingen, Germany) systems. A number of randomised controlled
    trials have demonstrated safety advantage in terms of reduced trocar site bleeding with radially expanding
    trocars.20,33–35
    Further miniaturisation of optical systems has resulted in the invention of an optical Veress needle
    but despite the theoretical advantages of such a device there is no evidence to demonstrate the
    superiority of this approach over the conventional Veress needle.36

    8.3. Alternative sites for primary trocar or Veress needle insertion
    What alternative sites can be safely used for primary trocar or Veress needle insertion?
    Palmer’s point is the preferred alternative trocar insertion site, except in cases of previous surgery in
    this area or splenomegaly.
    The rate of adhesion formation at the umbilicus may be up to 50% following midline laparotomy
    and 23% following low transverse incision.37 The umbilicus may not, therefore, be the most
    appropriate site for primary trocar insertion following previous abdominal surgery. The most usual
    alternative site is in the left upper quadrant, where adhesions rarely form, although even this may
    be inappropriate if there had been previous surgery in this area or splenomegaly. The preferred
    point of entry is 3 cm below the left costal margin in the mid-clavicular line (Palmer’s point). A small
    incision is made and a sharp Veress needle inserted vertically. Testing for correct placement using
    the pressure/flow test is performed. CO2 is then instilled to 25 mmHg pressure and a 2–5 mm
    endoscope is used to inspect the undersurface of the anterior abdominal wall in the area beneath
    the umbilicus. If this is free of adhesions, the trocar and cannulae can be inserted under direct
    laparoscopic vision. If there are many adhesions present, it is possible to dissect these free via
    secondary ports in the lower left abdomen or an alternative entry site can be selected visually.
    Other sites have been tried but, in general, are to be avoided. Suprapubic insertion of the Veress
    needle puts the bladder at risk of damage and is associated with the highest rate of failure due to
    preperitoneal insufflation of gas.9 Instillation of gas through the uterine fundus with the Veress
    needle carries the possibility of introducing infection and can be dangerous if bowel is adherent to
    the fundus. Similarly, entry through the posterior fornix could cause serious problems if the woman
    was found to have deep infiltrating endometriosis with obliteration of the cul-de-sac and the rectum
    adherent to the back of the cervix. A low rectal perforation at this site could be particularly
    dangerous and it should only be used when imaging techniques have clearly shown that the
    posterior cul-de-sac is free from deep infiltrating endometriosis and adherent bowel.

    9. Secondary ports
    How should secondary ports be inserted?
    Secondary ports must be inserted under direct vision perpendicular to the skin, while maintaining the
    pneumoperitoneum at 20–25 mmHg.
    During insertion of secondary ports, the inferior epigastric vessels should be visualised
    laparoscopically to ensure the entry point is away from the vessels.
    During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be
    angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.
    Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed
    and treated, if present.

    10. The woman who is obese
    What specific measures are required for laparoscopic surgery in the obese woman?
    The open (Hasson) technique or entry at Palmer’s point are recommended for the primary entry in
    women with morbid obesity. If the Veress needle approach is used, particular care must be taken to
    ensure that the incision is made right at the base of the umbilicus and the needle inserted vertically into
    the peritoneum.
    Women who are grossly obese are at a significantly greater risk of complications when undergoing
    laparotomy. Laparoscopic surgery may therefore be of particular benefit to these individuals. It is
    generally recommended that an open (Hasson) technique should be performed for primary entry
    in women who are morbidly obese, although even this technique may be difficult. If a Veress needle
    approach is used in the woman who is morbidly obese, it is important to make the vertical incision
    as deep as possible in the base of the umbilicus, since this is the area where skin, deep fascia and
    parietal peritoneum of the anterior abdominal wall will meet. In this area, there is little opportunity
    for the parietal peritoneum to tent away from the Veress needle and allow preperitoneal
    insufflation and surgical emphysema. If the needle is inserted vertically, the mean distance from the
    lower margin of the umbilicus to the peritoneum is 6 cm (± 3 cm). This allows placement of a
    standard length needle even in extremely obese women.38 Insertion at 45 degrees, even from within
    the umbilicus, means that the needle has to traverse distances of 11–16 cm, which is too long for
    a standard Veress needle.39

    11. The woman who is very thin
    What specific measures are required for laparoscopic surgery in the woman who is very thin?
    The Hasson technique or insertion at Palmer’s point is recommended for the primary entry in women
    who are very thin.
    Women at highest risk of vascular injury are the young, thin, nulliparous women with welldeveloped
    abdominal musculature; patients with severe anorexia are at particular risk. The aorta may lie less than 2.5 cm below the skin in these women.40 Great care, therefore, must be taken
    when performing first entry and a Hasson approach or insertion at Palmer’s point is preferable in
    this situation.
    7 of 10 RCOG Green-top Guideline No. 49

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