RU2306899C2 - Method for introducing veresh' needle and the first trocar in case of gynecological surgical laparoscopic operations in patients with laparotomy in anamnesis - Google Patents

Abstract

FIELD: medicine, laparoscopic gynecology.

SUBSTANCE: it is necessary to fulfill the puncture of abdominal cavity followed by paracentesis with a trocar, moreover, Veresh' needle and the first trocar should be introduced in cranial direction at the angle of 60°-70° through intraumbilical semilunar horizontal incision. During gynecological laparoscopic operations in patients with inferior-median laparotomies according to Phannenstihl technique in anamnesis. During surgical laparoscopic operations at the upper part of abdominal cavity and superior-median laparotomies in anamnesis one should fulfill a semilunar horizontal incision inside umbilical ring being nearer inferior edge in caudal direction at the angle of 45°. The innovation enables to avoid the lesion of abdominal organs that take part in post-surgical adhesive process, it does not prolong the terms of operation and requires no application of additional testing and equipment.

EFFECT: higher efficiency.

2 ex

Description

The invention relates to medicine, namely to laparoscopic gynecology and surgery.

For a long time, the doctors have been particularly interested in the technique of safely performing laparoscopic operations in patients with a history of gluttony, since the risk of iatrogenic damage to the abdominal organs in this situation is extremely high. Until recently, transferred laparotomy was considered a contraindication to laparoscopy [4, 9].

As you know, any surgical intervention on the abdominal organs usually leads to the formation of adhesions. This circumstance is a factor in the increased risk of unforeseen damage to internal organs during laparoscopic surgery [3, 4].

It has been proven that the severity of the adhesive process after operations on the abdominal organs depends on the nature of the gluttony and is proportional to the number of surgical interventions [2, 3, 4].

According to L.V. Adamyan et al. [2] the incidence of adhesions after gynecological surgery by gluttony was 88.7%, after appendectomy - 86.3%. According to O.V. Aziev et al. [3] adhesions were noted in 40.95% of patients with a history of surgical interventions. In women previously operated with laparoscopic access, adhesions were not detected in any case. Among patients with a transverse suprapubic section, adhesions were detected in 30.69% of cases, and after lower middle laparotomy - 41.86% of cases. Among patients who underwent two surgical interventions, adhesions were identified in 49.9% of cases, three - in 89.09%. Foreign authors noted the presence of adhesions in 57-60% of patients after one laparotomy and in 93% after repeated operations [15, 16].

Traditional laparoscopy technically involves entering the abdominal cavity through three “blind” actions: insertion of a Veress needle, application of pneumoperitoneum and insertion of a trocar [1, 5, 6, 9, 13].

The incision in the navel has a horizontal or vertical position. During gynecological operations on the small pelvis, the Veress needle is inserted at an angle of 45 ° and sent to the side of the sacral cavity, the patient is in a horizontal position. In obese people, the needle is inserted more vertically. To reduce the risk of damage to the abdominal organs with the introduction of a needle, the anterior abdominal wall is raised. Traction is carried out either by the hoes superimposed on the umbilical ring, or by the hand on the abdominal wall. Then create a pneumoperitoneum and introduce the first trocar in a blind way, directing it just like the Veress needle caudally. With cholecystectomies, a skin incision is applied in the umbilical ring or in the paraumbilical region, where the peritoneum is relatively thin. The trocar is directed cranially, at an angle of 60 °.

Due to the fact that the “blind” introduction of the first trocar is the most dangerous stage of laparoscopy [11], and in patients with an alleged adhesion process, the risk of severe complications increases many times, tests were developed to verify the correct insertion of the Veress needle and alternative methods of laparoscopy reduce the risk of trauma to the abdominal cavity [4, 7, 8, 9, 11, 12, 13, 15].

Currently, the following tests are used to verify the correct insertion of the Veress needle into the abdominal cavity [1, 7, 9, 10, 11, 12, 13, 15]:

1. When the tip of the needle enters the free abdominal cavity, a failure and click of the movable mandrel of the needle are felt, and a characteristic hiss of air drawn into the abdominal cavity is heard, which is associated with negative pressure.

2. Drip test - lift the abdominal wall, creating a negative pressure, a drop of liquid slides inward. If the needle is not in the correct position, the drop remains in place.

3. Injection-aspiration of the fluid through the needle - 5-10 ml of physiological saline are injected through the needle. The return of fluid when pulling the piston indicates that the tip of the needle is not in a free, but in a limited cavity. The return of fluid along with blood or intestinal contents signals a puncture of the internal organ.

4. The free arcuate movement of the needle indicates the absence of adhesions in the anterior abdominal wall.

5. Traction test: consists in the fact that the movable mandrel of the needle is advanced from its proximal end only when the tip of the needle meets an obstacle. Therefore, if the needle is in the abdominal cavity, then with its short movements along the axis back and forth, the mandrin remains stationary. If the needle does not stand correctly, then the proximal end will advance during movement.

6. Hardware test. The gas supply cannula is connected to the Veress needle mandrin and the insufflator is turned on. The device registers negative pressure in the abdominal cavity, which indicates the correct location of the needle.

7. The disappearance of hepatic dullness.

However, none of these tests is absolutely reliable, with the exception of fluid injection-aspiration, which, in turn, increases the time of surgery and is not safe in terms of contamination of the intestinal contents with the abdominal cavity. A single drop placed at the distal end of the needle will be aspirated by the negative pressure that is created by increasing any confined space, in particular the preperitoneal. A small initial insufflation is possible if the tip of the needle is in some kind of hollow and extensible organ. Tympanitis can be observed with percussion of cavities filled with gas. The disappearance of hepatic dullness is a late sign that appears after the introduction of up to 500 cm ^{3 of} gas [1, 9]. The sense of failure and click of the mandrel of the Veress needle is subjective. However, some authors do not recommend conducting a traction test or free arcuate movement with a needle [13, 15].

Alternative methods of laparoscopy are known that are used to enter the abdominal cavity in patients with a history of gluttony:

1. Technique using high pressure pneumoperitoneum. To reduce the likelihood of injuries associated with the initial introduction of the trocar, J. Hulka, H. Reich (1998) proposed a simple technique using high pressure pneumoperitoneum. After the introduction of the Veress needle and the creation of pneumoperitoneum at the level of 30 mm Hg in the deepest part of the navel, a short trocar is inserted through a vertical intra umbilical incision. The high pneumoperitoneum pressure used during the initial administration of the trocar is reduced immediately after confirmation of the noninvasive penetration into the abdominal cavity. G.Phillips et al. (1996) demonstrated that high intra-abdominal pressure significantly increases the distance between the anterior abdominal wall and large retroperitoneal vessels. This technique of introducing a trocar was used during 3041 operations [Vidali A., Reich H. Et al., 1998]. The umbilical introduction of the trocar was never accompanied by a vascular injury, however, two cases of intestinal perforation were noted due to its fusion with the inner surface of the navel. There were no complications associated with a short-term increase in intra-abdominal pressure [9].

2. Atypical points of introduction of trocars and double laparoscopy. Some surgeons to prevent a history of abdominal damage in patients with a history of gluttony have suggested a first puncture of the anterior abdominal wall at atypical points, i.e. away from the navel. To this end, M. Cohen and Scocia in 1991 developed a double laparoscopy technique using the region of the left hypochondrium. In this case, the Veress needle is introduced in the upper left quadrant along the front axillary line of the lateral rectus abdominis muscle two fingers below the costal arch. This choice also helps to avoid injury to a.epigastrica superior, which extends along the outer edge of the rectus abdominis muscle and anastamoses at the level of the navel with the inferior hypogastric artery. Then, under the control of a telescope introduced into this trocar, a place free from fusion in the umbilical region for a 10 mm trocar is chosen [4, 9, 14]. A similar technique is used by other authors, but the Veress needle is inserted in the ninth intercostal space along the anterior axillary line. This approach is due to the fact that the parietal peritoneum in this place is separated from the skin only by a layer of intercostal muscles and fascia, and there is practically no subcutaneous tissue. But there is a risk of injury to the diaphragm and the formation of pneumothorax. Contraindications are splenomegaly, bloating, swelling of the abdominal cavity. The technique requires an additional puncture and the presence of a 5 mm laparoscope. Carrying out such manipulations in the right intercostal space is excluded due to the high risk of liver injury [4, 14].

In women, it is also possible to insert a needle through the posterior vaginal fornix, provided that the uterus is mobile and there are no pathological formations in the posterior space, followed by puncture with a 5 mm trocar. The method is not widespread due to the technical complexity of manipulation and the danger of organ injuries in adhesions of the pelvis, caused by chronic inflammation of the genitals and more common adhesions caused by surgical interventions. There is also a risk of infection entering the abdominal cavity from the vagina and dyspareunia for a long time after surgery [9, 13].

3. In 1971, H.M. Hasson proposed the concept of open laparoscopy to avoid damage associated with "blind" entry into the abdominal cavity. The author designed a special cannula, now bearing his name. The procedure consists in dissecting a small incision at the level of the navel of the abdominal wall, applying a purse string suture to the aponeurosis and (or) peritoneum, or one seam from the edges. After that, the trocar is inserted into the abdominal cavity in a blunt way without a stylet. This method is a minilaparotomy [1, 7, 9, 11, 13, 15]. This method is relatively safe, but requires a large incision length, which causes a potential risk of hernia formation and careful wound sealing. This technique increases the duration of the operation [9, 13, 15].

4. The introduction of a trocar under the control of a video monitor.

The idea of introducing the first trocar under the control of a video system in patients with a history of gluttony belongs to Kiel University professor K. Zemm, it was proposed in 1973. The author made a skin incision and inserted a straight cannula with a 5 mm laparoscope to the peritoneum, then exfoliated the parietal peritoneum using gas and then evaluated the light reflection of the underlying tissues. The soldered intestine or omentum looks like a bright spot, in the absence of an adhesion process, it looks like a dark spot, where the peritoneum is penetrated. In recent years, some companies have developed Veress optical needles and Vidiotrocars (Visiport, Auto Suture, Ternamian Endotype System), which allow visual inspection of the first puncture of the anterior abdominal wall. This type of equipment is very expensive and therefore inaccessible for widespread use in our clinics [1, 4, 9, 14].

5. Direct introduction of the trocar.

The technique is based on the assumption that the complications of laparoscopic entry into the abdominal cavity are caused to a greater extent by the introduction of a Veress needle and carbon dioxide insufflation. Such access was first described by Dingfelder in 1978 and subsequently used by other endoscopists. The surgeon with his hand lifts the front abdominal wall, while creating negative pressure in the abdominal cavity. The first trocar is carried out through all layers of the anterior abdominal wall in the midline subumbilically, then a laparsocope is introduced and the surrounding tissues are examined. Advantages: direct access is shorter by 4, 3 min [1, 4, 9, 14].

However, it is doubtful that the rejection of the Veress needle is of such great importance. The most common complication associated with the use of the Veress needle is the insufflation of gas into the extraperitoneal space. In the Jansen study on analysis of 25764 laparoscopic operations, only 5 complications arose as a result of the insertion of a Veress needle, while the introduction of a trocar had 68 such complications. The technique of direct injection does not allow to avoid damage to the intestines soldered to the anterior wall [4, 14].

6. To visualize the adhesion process in the area of the introduction of the trocar, ultrasonic control has been proposed [8, 11]. According to I.A.Krasnov et al. (2002) the following signs are diagnostically significant, suggesting the presence of an adhesion process in the studied areas: 1) the lack of displacement of organs relative to the parietal peritoneum at local points; 2) the symptom of "recoil" or "return" is the reverse displacement of tissues and organs of the abdominal cavity that occurs at the depth of inspiration during forced breathing due to stretching and subsequent reduction of extended visceroparietal adhesions. According to the authors, the accuracy of ultrasound was confirmed by laparoscopy in 96% of studies [8]. This technique requires additional examination methods.

7. Most commonly used are the traditional entry into the abdominal cavity using the Palmer test. This test is designed to determine whether the location of the needle is free of adhesions or intestinal loops as a result of previous operations. After insertion of the Veress needle, the abdominal cavity is filled with carbon dioxide. A half-filled syringe with a needle punctures the abdominal cavity next to the needle in the estimated direction of movement of the first trocar, due to increased pressure, the contents of the abdominal cavity are aspirated into the syringe. Pure gas shows that the place is free, the absence of aspirate or blood indicates adhesions, turbid liquid indicates a puncture of the intestinal loop. Repeated repeatedly in various places of the anterior abdominal wall until they receive clean gas [10, 11, 12]. This technique does not exclude bowel injury and the development of purulent complications at the puncture sites with a Veress needle and a puncture needle.

The variety of alternative options for introducing the Veress needle and the first trocar into the abdominal cavity and tests for their control indicates that absolutely safe methods do not exist to date. The choice of technique for entering the abdominal cavity depends on the surgeon’s qualifications, his personal preferences, the number and nature of the patient’s history of surgical interventions, and the technical equipment with special equipment.

The objective of the invention: the development of a technically affordable and safe way of entering the abdominal cavity during laparoscopic surgery in patients who have a history of lower middle laparotomy, Pfannenstiel laparotomy and upper middle laparotomy. This technique is used in cases where the postoperative scar does not bend around the umbilicus and ends either below the navel (with lower middle laparotomies and Pfannenstiel laparotomies) or above the navel (with upper middle laparotomies).

With mid-median laparotomy, we enter the abdominal cavity either through a paraumbilicar point 2-4 cm above the navel (along the edge of the skin postoperative scar) along the midline and go in the cranial direction, or, with the alleged adhesive process in the upper floor of the abdominal cavity, choose the Monroe point (the contralateral Mac Burney point), because even in non-operated patients, in 20% of cases we find adhesions in the area of the cecum dome.

The claimed method of entry into the abdominal cavity with lower middle laparotomy and laparotomy according to Pfannenstiel in the anamnesis is as follows:

1. A semilunar horizontal incision is made inside the umbilical ring closer to the upper edge, after stretching the navel on the slippers.

2. To increase the free space of the abdominal cavity, we traction upward behind the abdominal wall, which we grab by hand in the longitudinal direction.

3. Puncture of the anterior abdominal wall is performed with a Veress needle in the cranial direction at an angle of 60-70 ° through an intra umbilical cilunar horizontal incision, displacing its upper edge with a Veress needle up by 1.0-1.5 cm, where the aponeurosis is punctured. A sharper angle (45 °) increases the likelihood of gas entering the round ligament of the liver.

4. Then we carry out tests according to known methods:

1) traction test - consisting in the fact that the movable mandrel of the needle is advanced from its proximal end only when the tip of the needle meets an obstacle. Therefore, if the needle is in the free abdominal cavity, then with its short movements along the axis back and forth, the mandrin remains stationary. If the needle does not stand correctly, then the proximal end will advance during movement.

2) hardware test - during gas insufflation, a low pressure (from -1 to 7 mm Hg) is recorded, which increases evenly, and a uniform gas flow rate (from 2.0 to 1.1 l / min).

3) with the introduction of up to 500 ml of gas, we determine tympanitis in the lower abdomen (a sample similar to the test for the disappearance of hepatic dullness).

The maximum rate of carbon dioxide through the Veress needle is 2.0 l / min, the maximum pressure created in the abdominal cavity before the first trocar is inserted is 14-20 mm Hg, the approximate amount of carbon dioxide injected depends on the volume of the patient’s abdominal cavity and is from 2.5 to 4.0 liters.

5. Analogously to the introduction of the Veress needle, we introduce a 10 or 5 mm trocar:

We perform an upward traction of the abdominal wall, which we grab in the longitudinal fold with the hand above the navel, with the end of the trocar, the skin flap moves up and 1.0-1.5 cm above the skin incision and we introduce the trocar at an angle of 60-70 °.

6. We make a control examination of the abdominal cavity.

The method of entry into the abdominal cavity with upper midline laparotomy in the anamnesis is carried out similarly to the above, differing in section, direction of insertion of the Veress needle and trocar.

1. A semilunar horizontal incision is made inside the umbilical ring closer to the lower edge, after stretching the navel on the hoes.

2. Traction upward behind the abdominal wall, which we grab with the hand in the longitudinal direction only in the hypogastric region, because capture in the mesogastric region does not give the maximum increase in free space.

3. Puncture of the anterior abdominal wall with the Veress needle is done caudally at an angle of 45 °, displacing the skin flap with the Veress needle down by 1.0-1.5 cm. In obese patients, the angle of introduction of the Veress needle is more obtuse (60 or more degrees).

4. Then we carry out the above tests: traction, hardware, with the introduction of up to 500 ml of gas, we determine the disappearance of hepatic dullness.

5. Analogously to the introduction of the Veress needle, we introduce a 10 or 5 mm trocar:

We perform an upward traction of the abdominal wall, which we grab in the longitudinal fold with the hand above the navel, with the end of the trocar, the skin flap moves up and 1.0-1.5 cm above the skin incision and we introduce the trocar at an angle of 60-70 °.

6. We make a control examination of the abdominal cavity.

For 1999-2004, we operated 2467 patients with surgical, gynecological and urological pathology with laparoscopic access. In all cases, with a history of gluttony, we used the above technique. There were no complications associated with injuring internal organs or large vessels when entering the abdominal cavity.

To study the adhesion process after surgical interventions in the anamnesis, 468 random protocols taken by us were analyzed, gynecological laparoscopic operations from 1999 to 2004.

A history of surgical interventions was revealed in 131 (27.99 ± 4.15%) patients. 101 people were operated once and 30 people had two or more surgical interventions. We were interested in 72 cases with a lower middle laparotomy and a history of Pfannenstiel gluttony in connection with the need for him to perform surgery on the pelvic organs with laparoscopic access.

To all patients, the Veress needle and the first trocar were introduced into the abdominal cavity as described above. In no case were there any complications.

During revision of the abdominal organs, an adhesion process between the internal organs of the abdominal cavity and the parietal peritoneum of the anterior abdominal wall was detected in 27 (90.0% ± from 77% to 98%) people with lower middle laparotomy and in 23 (54.76 ± 15.36%) ) a person with laparotomy according to Pfannenstiel. Of these, in 43 cases, one omentum was fixed to the parietal peritoneum. The intestine, together with the omentum, entered the adhesion process in 7 (14.0% ± from 5.90% to 24.80%) cases.

Given that the proposed access is 1-1.5 cm above the umbilical ring, during operations we noted a distance of less than 3 cm from the first trocar inserted to the adhesion process with the parietal peritoneum of the anterior abdominal wall. The first trocar was introduced within two centimeters of the adhesion process in only five cases with a history of lower middle laparotomy. In all other cases, the distance from the first trocar to the adhesion process exceeded 3 cm.

The average time of entry into the abdominal cavity in the operated and non-operated patients was 2.90 ± 0.15 and 2.65 ± 0.14 minutes, respectively (p> 0.05).

Example 1. Patient I., 29 years old, was admitted to the endoscopic surgery department for surgical treatment with a diagnosis of Cyst of the left ovary. Chronic salpingoophoritis. Chronic pelvic pain syndrome.

In history, in 1997, against the background of uterine perforation after the introduction of IUDs, pelvioperitonitis developed, sanitation of the abdominal cavity was performed using the lower middle access. A month later, a laparotomy was performed according to Pfannenstiel, an adnexectomy on the right, a tubectomy on the left due to purulent inflammation of the uterine appendages.

During laparoscopy, the Veress needle and the first trocar were inserted into the abdominal cavity in the cranial direction at an angle of 60 ° through a half-moon horizontal incision inside the umbilical ring closer to the upper edge, after stretching the navel on the slippers, after traction with the hand up over the abdominal wall according to the method described above. The time of entry into the abdominal cavity was 2 minutes 25 seconds. Then the abdominal cavity was revised: the omentum was soldered over the scar of the anterior abdominal wall over a distance of more than 4 cm below the trocar puncture. No injuries to organs and omentum. In the small pelvis there is a pronounced adhesion process between the bladder, the bottom of the uterus and the omentum. A loop of the small intestine and its mesentery are soldered to the posterior wall of the uterus. Right appendages are absent. On the left, the ovary with a yellow body cyst up to 4 cm is fixed to the sigmoid colon and its suspensions. The degree of adhesion was evaluated by the classification of Diamond (1987) as the third. Separation of adhesions, husking of an ovarian cyst was performed. The postoperative period was uneventful. Discharged in satisfactory condition on the 7th day.

Example 2. Patient I., 43 years old, was admitted to the endoscopic surgery department for laparoscopic cholecystectomy with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. A history of 13-year-old upper-mid laparotomy, splenectomy for autoimmune thrombocytopathy.

During a laparoscopic operation, the Veress needle was inserted caudally at an angle of 45 ° through a semilunar horizontal incision inside the umbilical ring closer to the lower edge, after stretching the navel on the slippers, after traction with the arm up behind the abdominal wall. After creating pneumoperitoneum, a 10 mm trocar was introduced in the same direction. The time of entry into the abdominal cavity was 2 minutes 35 seconds.

During revision of the abdominal cavity, an adhesive process was revealed between the omentum and the anterior abdominal wall to the left of the round ligament of the liver, the right lobe of the liver is locally fixed to the diaphragm. The adhesion process is located more than 4 cm from the insertion point of the first trocar. The gland envelops the gallbladder and is fixed to it; in the region of the Hartmann pocket and cystic duct, the transverse colon is fixed with planar commissures. With the introduction of the trocar, there were no wounds to the omentum or abdominal organs. After adhesiolysis, a typical cholecystectomy is performed.

The postoperative period was uneventful. Discharged on the 5th day in satisfactory condition.

Thus, the advantages of this technique in contrast to traditional methods are:

1. Given the absence of complications in the form of injuries to organs and large vessels associated with the introduction of the Veress needle and the first blind trocar in patients with a history of gluttony, this technique is safe.

2. The proposed technique is fundamentally different from the traditional technique in the direction of insertion of the Veress needle and the first trocar depending on the type of gluttony in the anamnesis and does not increase the time of penetration into the abdominal cavity compared to traditional access.

3. This technique does not require additional methods of examination or the use of additional equipment.

Literature

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Claims (1)

The method of introducing the Veress needle and the first trocar during gynecological and surgical laparoscopic operations in patients who have a history of glancing, including abdominal puncture followed by a trocar puncture, characterized in that the Veress needle and the first trocar are inserted in the cranial direction at an angle of 60-70 ° through intra umbilical lunar horizontal incision, during gynecological laparoscopic operations in patients with lower middle laparotomy according to Pfannenstiel in the anamnesis, during surgical laparoscopy x operations on the upper floor of the abdominal cavity and upper midline laparotomy in the history of performing a lunar horizontal incision inside the umbilical ring, closer to the lower edge in the caudal direction at an angle of 45 °.