A modified instrument and method for laparoscopy

Abstract

The laparoscope has become an important tool of modern gynecologic diagnosis and surgical treatment. The current laparoscopy technique entails the blind introduction of a needle into the peritoneal cavity to establish a pneumoperitoneum. The abdominal wall is then punctured with a cannula bearing a sharp trocar again blindly. The trocar is withdrawn and the lighted laparoscope is inserted through the cannula into the peritoneal cavity for visualization. A technique of performing laparoscopy through a mini laparotomy incision has been developed. The regular Wolf laparoscope cannula with a trumpet valve is fitted with a thin cone shaped stainless steel sleeve mounted on the cannulas shaft with the cone apex facing downward. A blunt obturator protruding 1 cm from the tip of the cannula is also provided. The cone sleeve acts life a cork to seal the peritoneal and fascial gap by advancing the cone deeper through the incisional opening much like a cork is pushed through a bottle neck. The cork cannula was developed jointly by the author and L. Streifeneder of the Eder Instrument Company. The skin of the abdominal wall is prepared and draped. A small transverse curved incision 3-4 cm long is made through the skin of the lower edge of the umbilical fossa and the skin edges are retracted first with 2 Allis clamps then with a small self-retraining retractor. The subcutaneous adipose tissues are reflected. The linea alba which may be present in 1 or more distinct fascial layers is grasped with 1 or more sets of Kocher clamps incised and suture tagged. The incision is made longitudinally toward the umbilicus for approximately 1/2 inch. The subserous or subperitoneal fascia is next picked up and incised. The exposed peritoneum is then incised vertically for a distance of slightly over 1 cm. 2 sutures are passed 1 through each peritoneal edge and tagged. The peritoneal sutures are gently held apart and the cork-like cannula carrying the blunt obturator is inserted through the opening into the peritoneal cavity. The obturator is withdrawn and gas is insufflated through the cannula to effect a pneumo-peritoneum. To prevent the escape of gas the cork cannula is inserted further as required to effectively block the incisional gap. With an adequate pneumoperitoneum the scope is introduced through the cannula and the procedure is continued as usual. The new open method eliminates certain flaws of the blind method: the use of a needle or sharp trocar directed blindly and forcibly to puncture the abdominal wall is eliminated; placing the gas consistently into the peritoneal cavity is assured since the peritoneum is incised under vision in every case; and the inaccessible tear caused by the blind insertion of a sharp trocar is avoided by a planned fascial and peritoneal incision which is anatomically repaired at the end of the procedure.