Surgical Techniques
How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy
By arming yourself with knowledge of the most common complications—and their causes—and employing well-chosen surgical strategies, you can lower...
CASE: OBESE PATIENT REQUESTS TOTAL LAPAROSCOPIC HYSTERECTOMY
A 45-year-old woman (G2P2), who delivered both children by cesarean section, schedules an office visit for a complaint of abnormal uterine bleeding. She is obese, with a body mass index (BMI) of 35 kg/m2, and has an enlarged uterus of approximately 14 weeks’ size with minimal descensus. An earlier trial of hormone therapy failed to provide relief. After you counsel her extensively about her treatment options, she elects to undergo total laparoscopic hysterectomy.
What anatomy would you review to help ensure the procedure’s success?
Although the vaginal route is preferred for hysterectomy, total laparoscopic hysterectomy is another minimally invasive option that offers lower morbidity and a shorter hospital stay than the abdominal approach.1 Perhaps more than any other variable, the key to safe, efficient, and effective laparoscopic surgery is a comprehensive knowledge of anatomy. For example, a thorough understanding of the anatomy of the anterior abdominal wall is critical to laparoscopic entry.2,3 Also, pelvic anatomy visualized two-dimensionally under magnification during traditional laparoscopy can look very different than it does during conventional surgery, due to the effects of the pneumoperitoneum, steep Trendelenburg position, and/or the use of uterine manipulators.3
The abdominal cavity is traditionally divided into nine regions. Regardless of the quadrants chosen for laparoscopic access, thorough knowledge of the relevant surface anatomy increases patient safety during surgery (FIGURE 1).
PRIMARY PORT PLACEMENT
Primary port placement, including insertion of the Veress needle, accounts for approximately 40% of laparoscopic complications.4 To help minimize complications, surgeons should ensure that the operating table remains level during placement. As the patient is moved into the Trendelenburg position, the great vessels are more in line with the 45-degree angle that most surgeons use when placing their Veress needle and primary trocar, which can lead to an increased risk of injury. Thus, proper positioning in relationship to anatomy is critical to successful laparoscopic surgery.
Veress or closed technique
Most gynecologists employ the closed method or Veress needle approach to establish pneumoperitoneum.5,6 an initial intraperitoneal pressure below 10 mm Hg, regardless of a woman’s body habitus, height, or age, indicates correct placement of the Veress needle.7,8 Vilos and colleagues demonstrated that Veress intraperitoneal pressure correlates positively with a woman’s weight and BMI and correlates negatively with her parity.8
Hasson or open technique
During the Hasson or open technique, many surgeons use the umbilical ring to gain entry into the abdominal cavity.9 Many view the umbilical ring as a window into the anterior abdominal wall, through which access to the peritoneal cavity can be achieved, but it can also be a site of hernia development.10 The shape of the umbilical ring can vary, appearing round or oval, but it also can be obliterated, slitted, or covered completely by a connecting band, which can result in more difficult laparoscopic entry.10
Palmer’s point
In the 1940s, the French gynecologist Raoul Palmer advocated placing the laparoscope at a point in the left midclavicular line, approximately 3 cm caudal to the costal margin, because visceral-parietal adhesions rarely were found there. Gynecologists still favor this entry site when intra-abdominal adhesions are likely, especially in patients with a history of significant adhesions or multiple previous pelvic surgeries.11 In a study published by Agarwala and colleagues, which included 504 patients with intra-abdominal adhesions, left upper quadrant entry was found to be safe with a complication rate as low as 0.39%.12
If supraumbilical or left upper quadrant port sites are used, the surface anatomy of the spleen and stomach become relevant. The portion of the stomach that is in contact with the abdominal wall is represented roughly by a triangular area extending between the tip of the 10th left costal cartilage, the tip of the ninth right cartilage, and the end of the eighth left costal cartilage.13 The size and shape of the stomach differs by position. Some authors recommend emptying the stomach using a nasogastric or oral gastric tube prior to port insertion to avoid injury.12
The spleen can be mapped using the 10th rib as representing its long axis; vertically, the spleen is situated between the upper border of the ninth and lower border of the 11th ribs.13 In patients without splenic enlargement, the spleen should not be found below the rib cage.
Related article: Tips and techniques for robot-assisted laparoscopic myomectomy Arnold P. Advincula, MD, and Bich-Van Tran, MD (Surgical Technique, August 2013)
CASE CONTINUED
On the day of surgery, your patient is brought to the operating room. you use the Veress needle for insufflation. Your opening pressure is 5 mm Hg. You know that an opening pressure of less than 10 mm Hg indicates proper placement, so you continue on to place a 10-mm port. After inserting the primary umbilical port through the umbilicus, you decide to insert secondary ports through lower quadrants. Upon insertion, you note active bleeding at one of the secondary port sites.
