Abstract
Objectives
To describe three steps: (1) the initial Veress pressure (VIP-Pressure), (2) transient high-pressure pneumoperitoneum (HIP-Entry) prior to trocar/cannula insertion, and (3) visual entry with a trocarless cannula during closed laparoscopic entry, which may reduce major injuries.
Design
Prospective observational cohort study (Canadian Task Force Classification II-2).
Setting
University-affiliated teaching hospital.
Interventions
VIP-Pressure. During laparoscopic entry, the initial VIP pressure was measured and correlated against the body habitus and parity of 365 consecutive women. HIP-Entry was performed in 2,498 consecutive cases. In 100 women, the CO2 volume, heart rate, blood pressure, oxygen saturation, and pulmonary compliance were recorded at pressures of 10, 15, 20, 25, and 30 mmHg. Visual entry with a trocarless blunt cannula was performed in 776 women. The cannula, housing a 0° laparoscope, was rotated clockwise applying minimal downward force.
Measurements and results
VIP-Pressure. Pneumoperitoneum was established after one, two or three Veress needle attempts at the umbilicus in 82.4%, 10.9%, and 4.0% of women, respectively. In seven (2.2%), pneumoperitoneum was established at the left upper quadrant (LUQ) during the fourth attempt, and in two (0.6%) entry was abandoned. Median initial Veress pressure was 4 mmHg (range 2–10 mmHg). The VIP pressure correlated positively with women’s weight (r = 0.518, p < 0.001) and body mass index (BMI) (r = 0.545, p < 0.001), and negatively with parity (r = −0.179, p < 0.001). HIP-Entry. The abdomen was insufflated to 25−30 mmHg prior to primary trocar/cannula insertion. There were no changes in cardiovascular parameters between 15 and 30 mmHg. A 21% decrease in pulmonary compliance from 15 to 30 mmHg was of no clinical significance. No injury has been experienced with the visual cannula in 776 cases.
Conclusions
(1) A VIP-Pressure (<10 mmHg) indicates intraperitoneal placement of the Veress needle. (2) The use of transient HIP-Entry does not adversely affect cardiopulmonary function in healthy women. (3) Visual cannula offers an additional step towards safer entry.
Similar content being viewed by others
References
Vilos GA (2000) Litigation of laparoscopic major vessel injuries in Canada. J Am Assoc Gynecol Laparosc 7(4):503–509
Vilos GA (2002) Laparoscopic bowel injuries: forty litigated gynecological cases in Canada. J Obstet Gynecol Can 24(3):224–230
Magrina J (2002) Complications of laparoscopic surgery. Clin Obstet Gynecol 45:469–480
Jansen FW, Kolkman W, Bakkum EA et al (2004) Complications of laparoscopy: an inquiry about closed-versus open-entry technique. Am J Obstet Gynecol 190:634–638
Garry R (1999) Towards evidence based laparoscopic entry techniques: clinical problems and dilemmas. Gynecol Endosc 8:315–326
Molloy D, Kaloo PD, Cooper M, Nguyen TV (2002) Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Aust NZ J Obstet Gynecol 42(3):246–254
Fuller J, Scott W, Ashar B, Corrado J (2005) Laparoscopic Trocar Injuries: a report from a US Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) Systematic Technology Assessment of Medical Products (STAMP) Committee. 8/25/2005; pp 1–14. http://www.fda.gov/cdrh/medicaldevicesafety/stamp/trocar.htm. Accessed 25 August 2005
Vilos GA, Ternamian A, Dempster J et al (2007) Laparoscopic entry: a review of techniques, technologies, complications. Society of Obstetricians, Gynecologists (SOGC) clinical practice guideline no. 1993 May 2007. J Obstet Gynecol Can 29(5):433–447
Champault G, Cazacu F, Taftinder N (1996) Serious trocar accidents in laparoscopic surgery: a French survey of 103 852 operations. Surg Laparosc Endosc 6:367–370
Palmer R (1974) Safety in laparoscopy. J Reprod Med 13:1–5
Hasson HM (1971) A modified instrument and method for laparoscopy. Am J Obstet Gynecol 110(6):886–887
Dingfelder JR (1978) Direct laparoscopic trocar insertion without prior pneumoperitoneum. J Reprod Med 21:45–47
Yuzpe AA (1990) Pneumoperitoneum needle and trocar injuries in laparoscopy: a survey on possible contributing factors and prevention. J Reprod Med 35:485–490
Corson SL, Chandler JG, Way LW (2001) Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc 8:341–347
Lingan K, Cole R (2001) Laparoscopy entry port visited: a survey of practices of consultant gynecologists in Scotland. Gynecol Endosc 10:335–342
Merlin T, Hiller J, Maddern F et al (2003) Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. Br J Surg 90:668–670
Kaloo P, Cooper M, Molloy D (2002) A survey of entry techniques and complications of members of the Australian Gynecological Endoscopy Society. Aust NZ J Obstet Gynecol 42(3):264–266
Hasson HM (1999) Open laparoscopy as a method of access in laparoscopic surgery. Gynecol Endosc 8:353–362
Schafer M, Lauper M, Krahenbuhl K (2001) Trocar and Veress needle injuries during laparoscopy. Surg Endosc 15:275–280
Neudecker J, Sauerland S, Nengebauer F et al (2002) The European Association for Surgery Clinical Practice Guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 16:1121–1143
Vilos GA, Vilos AG (2003) Safe laparoscopic entry guided by Veress needle CO2 insufflation pressure. J Am Assoc Gynecol Laparosc 10(3):415–420
Abu-Rafea B, Vilos GA, Vilos AG et al (2005) High-pressure laparoscopic entry does not adversely affect cardiopulmonary function in healthy women. J Min Invas Gynecol 12(6):475–479
Vilos GA, Hancock G, Penava DA, Kozak I, Davies W (1999) Nine cases of bowel injury during 3472 laparoscopies. J Soc Obstet Gynecol Can 21(12):144–150
Rosen DM, Lam AM, Chapman M, Carlton M, Cario GM (1998) Methods of creating pneumoperitoneum: a review of techniques and complications. Obstet Gynecol Surv 53(3):167–174
Chandler JG, Corson SL, Way LW (2001) Three spectra of laparoscopic entry access injury. J Am Coll Surg 192:478–479
Teoh B, Sen R, Abbott J (2005) An evaluation of four tests used to ascertain Veress needle placement at closed laparoscopy. J Min Invas Gynecol 12:153–158
Garry R (1997) Complications of laparoscopic entry. Gynecol Endsoc 6:319–329
Richardson RF, Sutton CJG (1999) Complications of first entry: a prospective laparoscopic audit. Gynecol Endosc 8:327–334
Dubuisson JB, Chapman C, Decuypere F, DeSpirlet M (1999) ‘Classic’ laparoscopic entry in a university hospital: a series of 8 324 cases. Gynecol Endosc 8:349–352
Ricci M, Aboolian A (1999) Needle pneumoperitoneum: an alternative technique. Surg Endosc 13:629
Vilos AG, Vilos GA, Abu-Rafea B, Hollett-Caines J, Al-Omran M (2006) Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women. J Min Invas Gynecol 13:108–113
Abu-Rafea B, Vilos GA, Vilos AG, Hollett-Caines J, Al-Omran M (2006) Effect of body habitus and parity on insufflated CO2 volume at various intra-abdominal pressures during laparoscopic access in women. J Min Invas Gynecol 13:205–210
Thompson JD, Rock JA (1992) Diagnostic and operative laparoscopy. In: Te Lindes operative gynecology, 7th edn. Philadelphia. Lippincott, 1001, p 363
Nordestgaard AG, Bodily KC, Oshorye RW et al (1995) Major vascular injuries during laparoscopic procedures. Am J Surg 169:543–545
Bhoyrul S, Vierra MA, Nezhat Cr, Krummel TM, Way LW (2001) Trocar injuries in laparoscopic surgery. J Am Coll Surg 192:677–683
Agarwala N, Liu CY (2005) Safe entry technique during laparoscopy, left upper quadrant entry using the ninth intercostal space–A review of 918 procedures. J Min Invas Gynecol 12:55–61
Phillips G, Garry R, Kumar C, Reich H (1999) How much gas is required for initial insufflation at laparoscopy? Gynecol Endosc 8:365.74
Reich H, Rasmussen C, Vidali A (1999) Peritoneal hyperdistention for trocar insertion. Gynecol Endosc 8:375–377
Lam KW, Pun TL (2002) Left upper quadrant approach in gynecologic laparoscopic surgery with reusable instruments. J Am Assoc Gynecol Laparosc 9(2):199–203
Reich H, Robeiro SC, Rasmussen C, Rosenberg J, Vidali A (1999) High-pressure trocar insertion technique. J Soc Laparoendosc Surg 3:45–48
Garry R (1997) Complications of laparoscopic entry. Gynecol Endosc 6:319–329
Fuller J, Ashar BS, Carey-Corrado J (2005) Trocar-associated injuries and fatalities: An analysis of 1399 reports to the FDA. J Min Invas Gynecol 12:302–307
Sharpe HT, Dodson MK, Draper ML, Watts DA, Doucette RC, Hurd WW (2002) Complications associated with optical-access laparoscopic trocars. Obstet Gynecol 99:553–555
Ternamian AM (1997) Laparoscopy without trocars. Surg Endosc 11:815–818
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Vilos, G.A., Vilos, A.G., Abu-Rafea, B. et al. Three simple steps during closed laparoscopic entry may minimize major injuries. Surg Endosc 23, 758–764 (2009). https://doi.org/10.1007/s00464-008-0060-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-008-0060-4