LapCap: A Novel Device to Reduce Entry Complications

Abstract

Laparoscopy is one of the most common procedures performed worldwide. More than 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase. None of the available modalities for abdominal entry has a clear advantage over the others; however, Veress entry is currently the most popular approach among gynecologists. Major vascular injury during the initiation of pneumoperitoneum is a much-feared complication of laparoscopic procedures, associated with a reported mortality rate of 15%. This is because of the close proximity of the anterior abdominal wall to the retroperitoneal vascular structures, which in thin patients can be as little as 2 cm. This risk can be avoided by using the LapCap device (Aragon Surgical, Palo Alto, CA) at the time of Veress entry in thin patients (Fig. 1). The device is placed over the abdominal wall, with umbilicus at its center (Fig. 2, A). The suction is attached (Fig. 2, B). This elevates the abdominal wall into the dome, creating a cone-shaped vacuum space of peritoneal cavity within the vacuum cup dome (Fig. 2, C). The suction should be applied 3 times before insertion of the Veress needle, to displace the omentum and bowel from the anterior abdominal wall. The Veress needle can then be safely pierced through the umbilicus and pneumoperitoneum created (Fig. 2, D). The pressure reading at needle entry can be almost double the actual intra-abdominal pressure because of the smaller volume of the abdominal cavity within the vacuum cup. Once the pressure reaches 20 mm, the vacuum is released (Fig. 3, A). Subsequently, the intra-abdominal pressure may fall. The Veress needle is kept in place, and insufflation can be continued until the desired pressure is achieved (Fig. 3, B). The vacuum cup with the needle is then removed (Fig. 3, C), and the trocar is placed (Fig. 3, D). Lapcap was used in more than 15 patients. In all cases, needle entry was easy, successful, and without complications, although in the first several cases there was some initial doubt about the intraperitoneal location of the Veress needle [1Nezhat C. Nezhat C. Nezhat F. Ferland R. Lewis M. King L.P. Laparoscopic access.http://laparoscopy.blogs.com/prevention_management_3/2011/04/laparoscopic-access.htmlDate accessed: August 28, 2017Google Scholar]. One disadvantage of the LapCap device is that the small area of tissue in the cone can cause an artificially high pressure reading. A reading of up to 20 mmHg may be seen even with correct intraperitoneal placement; in most cases, the reading is approximately double the actual intraperitoneal pressure. Once the vacuum is released, the pressure reading will decrease by approximately 50%. Another drawback is the need to use another method, such as the saline drop test, to confirm intraperitoneal needle placement at first. After 2 or 3 cases, use of the LapCap becomes routine. In patients with previous surgeries, adhesions to the abdominal wall at the umbilicus may be a concern. Some centers use a mapping technique, particularly in patients with previous surgeries, after insufflation of the abdomen and before primary trocar placement. At our center, the LapCap device is placed at a site away from the umbilicus, most commonly Palmer's point. Another difference with the use of the LapCap is that no skin incision is made before insertion of the Veress needle. If a skin incision were made, the negative pressure from the vacuum would increase bleeding from the skin incision site. Thus, the surgeon should anticipate 3 “clicks” before intraperitoneal placement (skin, fascia, peritoneum), as opposed to the usual. The LapCap is a simple device for readily creating a pneumoperitoneum, especially in thin patients. The device can be used in obese patients as well, in whom the full length of a 15-cm Veress needle may need to be inserted, as opposed to <5 cm in thin patients. The LapCap can significantly reduce the risk of retroperitoneal injury associated with the use of the Veress needle. It is also can help decrease the number of attempts of abdominal entry, which is important because the risk of bowel and vessel injury increases with the number of entry attempts. The LapCap may be especially helpful in teaching residents who are first learning abdominal entry techniques, as well as others who are not so proficient in laparoscopic surgery.