Letter: Hazards of laparoscopy.

Abstract

I should like to refer to the mode of introduction of the pneumoperitoneum needle. It is this part of the operation which registars find most difficult and why we suggested (June 30, p. 773) a different site for insertion in the unexceptional case. I have the greatest admiration and respect for Mr. Patrick Steptoe (August 11, p. 347) but respectfully suggest that a technique which is easier to learn is likely to be safer as far as surgical trainees are concerned. In Winchester we have found that registrars find it easier to learn the technique of inserting the needle about halfway between the symphysis pubis and the umbilicus. The operator's left hand tenses the abdominal skin while palpating the sacral promontory. The needle "plunges" into the hollow of the pelvis with a distinctive feel. It is of course, essential that the patient is in the Trendelenburg position and that an assistant holds the Spackman's cannula in such a way as to antevert the uterus as far as possible. This method is contraindicated in patients with a pelvic tumor, when a technique such as described by Mr. Steptoe is preferred. This method is quite different from the standard technique because the abdominal wall is not lifted away from the posterior abdominal wall and relies for its safety in directing the needle into the pelvic cavity. We find it useful to keep the pneumoperitneum needle in situ; it can be used to display the pelvic viscera or aspirate cysts and often avoids the need to insert another trocar and cannula. Since adopting this technique (which is not unique to Winchester) we have had no laparoscopy failures. The uterus has been punctured 3 times in about 200 operations but with no sequelae. Trainees need to be taught the several means of introducing the pneumoperitoneum needle and, like Kejlland's forceps, this means tuition by the expert.