2197 Strategies for Laparoscopic Entry in Complex Patients

Abstract

Video Objective There are three general techniques for laparoscopic entry, all of which are considered safe and effective. These include the use of a veress needle, an optical trocar, and an open approach. Twenty-five percent of all injuries during laparoscopic surgery occur with initial entry. Therefore, a thoughtful approach to port placement is critical to ensure optimal performance and patient safety with entry. Certain patient factors that may increase the rate of injury or complicate entry include obesity, prior abdominal surgeries, large uterine size, and the small stature and short torso of the pediatric patient. We created a video to describe laparoscopic entry techniques in patients with co-morbid conditions in order to improve surgical planning and decrease the rate of injury. Setting We selected six patient scenarios that posed various challenges to safe laparoscopic entry at our large academic institution nested in an underserved urban environment. These scenarios included: morbid obesity, a large bulky uterus, previous abdominal surgeries, umbilical mesh from a herniorrhaphy, prior abdominoplasty, and the pediatric patient. Interventions We identified complexities of laparoscopic entry in surgical patients and then reviewed the literature to devise techniques to address these challenges. We present techniques for entry from an evidence-based literature review and expert opinion from minimally invasive gynecologic surgeons and general surgeons, for patients undergoing laparoscopic surgery in the aforementioned scenarios. Conclusion This video uses audio and visual components to review safe and effective strategies for laparoscopic entry. Through illustrations and surgical cases we offer tips in complex scenarios. We hope this video can serve as a resource to surgeons, particularly trainees, and improve confidence and surgical planning to ultimately decrease injury.