Skip to main content
SpringerLink
Log in

Three simple steps during closed laparoscopic entry may minimize major injuries

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Vilos GA (2000) Litigation of laparoscopic major vessel injuries in Canada. J Am Assoc Gynecol Laparosc 7(4):503–509

    Article  PubMed  CAS  Google Scholar 

  2. Vilos GA (2002) Laparoscopic bowel injuries: forty litigated gynecological cases in Canada. J Obstet Gynecol Can 24(3):224–230

    Google Scholar 

  3. Magrina J (2002) Complications of laparoscopic surgery. Clin Obstet Gynecol 45:469–480

    Article  PubMed  Google Scholar 

  4. 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

    Article  PubMed  Google Scholar 

  5. Garry R (1999) Towards evidence based laparoscopic entry techniques: clinical problems and dilemmas. Gynecol Endosc 8:315–326

    Article  Google Scholar 

  6. 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

    Article  Google Scholar 

  7. 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

  8. 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

    Google Scholar 

  9. 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

    Article  PubMed  CAS  Google Scholar 

  10. Palmer R (1974) Safety in laparoscopy. J Reprod Med 13:1–5

    PubMed  CAS  Google Scholar 

  11. Hasson HM (1971) A modified instrument and method for laparoscopy. Am J Obstet Gynecol 110(6):886–887

    PubMed  CAS  Google Scholar 

  12. Dingfelder JR (1978) Direct laparoscopic trocar insertion without prior pneumoperitoneum. J Reprod Med 21:45–47

    PubMed  CAS  Google Scholar 

  13. Yuzpe AA (1990) Pneumoperitoneum needle and trocar injuries in laparoscopy: a survey on possible contributing factors and prevention. J Reprod Med 35:485–490

    PubMed  CAS  Google Scholar 

  14. Corson SL, Chandler JG, Way LW (2001) Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc 8:341–347

    Article  PubMed  CAS  Google Scholar 

  15. Lingan K, Cole R (2001) Laparoscopy entry port visited: a survey of practices of consultant gynecologists in Scotland. Gynecol Endosc 10:335–342

    Article  Google Scholar 

  16. 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

    Article  PubMed  CAS  Google Scholar 

  17. 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

    Article  Google Scholar 

  18. Hasson HM (1999) Open laparoscopy as a method of access in laparoscopic surgery. Gynecol Endosc 8:353–362

    Article  Google Scholar 

  19. Schafer M, Lauper M, Krahenbuhl K (2001) Trocar and Veress needle injuries during laparoscopy. Surg Endosc 15:275–280

    Article  PubMed  CAS  Google Scholar 

  20. 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

    Article  PubMed  CAS  Google Scholar 

  21. Vilos GA, Vilos AG (2003) Safe laparoscopic entry guided by Veress needle CO2 insufflation pressure. J Am Assoc Gynecol Laparosc 10(3):415–420

    Article  PubMed  Google Scholar 

  22. 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

    Article  Google Scholar 

  23. 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

    Google Scholar 

  24. 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

    Article  PubMed  CAS  Google Scholar 

  25. Chandler JG, Corson SL, Way LW (2001) Three spectra of laparoscopic entry access injury. J Am Coll Surg 192:478–479

    Article  PubMed  CAS  Google Scholar 

  26. 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

    Article  Google Scholar 

  27. Garry R (1997) Complications of laparoscopic entry. Gynecol Endsoc 6:319–329

    Article  Google Scholar 

  28. Richardson RF, Sutton CJG (1999) Complications of first entry: a prospective laparoscopic audit. Gynecol Endosc 8:327–334

    Article  Google Scholar 

  29. 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

    Article  Google Scholar 

  30. Ricci M, Aboolian A (1999) Needle pneumoperitoneum: an alternative technique. Surg Endosc 13:629

    Article  PubMed  CAS  Google Scholar 

  31. 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

    Article  Google Scholar 

  32. 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

    Article  Google Scholar 

  33. Thompson JD, Rock JA (1992) Diagnostic and operative laparoscopy. In: Te Lindes operative gynecology, 7th edn. Philadelphia. Lippincott, 1001, p 363

  34. Nordestgaard AG, Bodily KC, Oshorye RW et al (1995) Major vascular injuries during laparoscopic procedures. Am J Surg 169:543–545

    Article  PubMed  CAS  Google Scholar 

  35. Bhoyrul S, Vierra MA, Nezhat Cr, Krummel TM, Way LW (2001) Trocar injuries in laparoscopic surgery. J Am Coll Surg 192:677–683

    Article  PubMed  CAS  Google Scholar 

  36. 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

    Article  Google Scholar 

  37. Phillips G, Garry R, Kumar C, Reich H (1999) How much gas is required for initial insufflation at laparoscopy? Gynecol Endosc 8:365.74

    Article  Google Scholar 

  38. Reich H, Rasmussen C, Vidali A (1999) Peritoneal hyperdistention for trocar insertion. Gynecol Endosc 8:375–377

    Article  Google Scholar 

  39. 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

    Article  PubMed  CAS  Google Scholar 

  40. Reich H, Robeiro SC, Rasmussen C, Rosenberg J, Vidali A (1999) High-pressure trocar insertion technique. J Soc Laparoendosc Surg 3:45–48

    CAS  Google Scholar 

  41. Garry R (1997) Complications of laparoscopic entry. Gynecol Endosc 6:319–329

    Article  Google Scholar 

  42. 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

    Article  Google Scholar 

  43. 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

    Article  Google Scholar 

  44. Ternamian AM (1997) Laparoscopy without trocars. Surg Endosc 11:815–818

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, St. Joseph’s Health Care, The University of Western Ontario, 268 Grosvenor St., London, ON, Canada, N6A 4V2

    George A. Vilos, Angelos G. Vilos, Basim Abu-Rafea, Jackie Hollett-Caines & Zohreh Nikkhah-Abyaneh

  2. King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

    Basim Abu-Rafea

  3. International Medical Centre, Jeddah, Saudi Arabia

    Fawaz Edris

Authors
  1. George A. Vilos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Angelos G. Vilos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Basim Abu-Rafea
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jackie Hollett-Caines
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zohreh Nikkhah-Abyaneh
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fawaz Edris
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to George A. Vilos.

Rights and permissions

Reprints 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

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-008-0060-4

Keywords

Search

Navigation