Les risques de la voie d’abord en cœlioscopie

Abstract

To provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using the key words: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, optical trocar radially expanded trocars, and laparoscopic complications. Except for high-risk subgroups, laparoscopic entry should be performed using one of the four followings techniques (grade B): trans-umbilical trocar insertion after creation of a pneumoperitoneum using Veress needle; open-laparoscopy (Hasson technique), left upper quadrant (LUQ) laparoscopic entry or trans-ombilical direct trocart insertion. Because of insufficient evaluation, radially expanding trocars and visual entry systems (optical trocars) should not be used as a first-line technique (grade C). Left upper quadrant (LUQ, Palmer's) laparoscopic entry technique should be used in patients with previous midline incision laparotomy (grade B). In pregnant women, the level of insertion of the first trocar should be adapted to uterine volume (grade B). In second trimester, an open (Hasson) or a LUQ technique should be performed (grade C). In third trimester, an open (Hasson) technique (above the level of uterine fundus) should be performed when a laparoscopy is indicated. For pneumoperitoneum establishment using Veress needle insertion, one or several Veress needle safety tests or checks should be done (grade B) and waggling of the Veress needle from side to side must be avoided, as this can enlarge a bowel or vascular injury. In the Veress needle method of entry, the abdominal pressure should be increased immediately prior to insertion of the first trocar (from 15 to 25 mmHg) (grade C). Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.