Lifting of the umbilicus for the installation of pneumoperitoneum with the Veress needle increases the distance to the retroperitoneal and intraperitoneal structures

Abstract

Background

In laparoscopy, 50% of all complications occur during establishment of the pneumoperitoneum. Elevation of the fascia is recommended for the Veress needle approach, although the benefit has not been proved to date. This study aimed to evaluate the intraabdominal changes during lifting of the fascia with regard to the distance from the fascia to the retroperitoneal vessels and the intestine for access in laparoscopy.

Methods

For 10 patients scheduled to undergo laparoscopic cholecystectomy, the operation started with the computed tomography (CT) scan. After orotracheal intubation, a CT scan of the umbilical region was performed. After a supraumbilical incision, the fascia was freed and elevated with stay sutures. During maximal elevation, a second CT scan was performed. Distances to the intestinal (small bowel) and retroperitoneal structures (iliac artery, vena cava) were measured. Intraabdominal pressure was measured with a transcystic balloon manometer before (a) and after (b) elevation of the fascia, after insertion of the Veress needle (c), and after completion of the insufflations (d).

Results

Lifting of the fascia increased the distance between the fascia and the intestinal structures in the patients with no prior abdominal surgery (mean distance, 1.92 cm; range, 0.87–2.67 cm) and the distance between the fascia and the retroperitoneal vessels (mean distance, 7.83 cm; range, 3–11 cm). The median intraabdominal pressures in terms of cm H₂O were 5.4 for a, 1.1 for b, 1.1 for c, and 12. 5 for d.

Conclusion

Elevation of the fascia before the first entrance to the abdominal cavity for laparoscopy may increase safety due to a significant enlargement of distance between the fascia and the retroperitoneal structures.