Abdominal Entry Research Articles

Single Port Access (SPA) Splenectomy

Over the last decade, laparoscopic splenectomy has become the standard of care for spleen removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multiport laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We apply the SPA technique to splenectomy via a single umbilical incision. SPA splenectomy was performed in a 36-year-old male for staging. The single-port access technique was used to gain abdominal entry. Exposure, dissection, and removal were performed via a single incision within the umbilicus. The final incision was extended for removal of a complete specimen for pathologic evaluation. Splenic mobilization and control of the short gastrics was successfully performed via a single umbilical incision. The final incision was extended inferiorly for en bloc organ removal. Follow-up at 18 months revealed a well-healed incision with no signs of hernia formation. The single-port access technique has been successfully applied to splenectomy as an available alternative to multiport laparoscopic splenectomy. Use of standard instrumentation and trocars maintains costs and familiarity of the procedure. Exposure, visualization, and dissection are the same as in standard laparoscopy. SPA surgery may be more ergonomically pleasing to the surgeon and offer patient benefits, such as faster recovery and decreased adhesion formation in the long term.

Recent Advances in the Surgical Management of Cervical Cancer

Recent advances in the surgical management of early cervical cancer, including abdominal, laparoscopic, vaginal, and robotic approaches to radical hysterectomy as well as fertility-sparing radical trachelectomy, are reviewed. The nerve-sparing abdominal radical hysterectomy technique allows for a significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates without abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to the traditional abdominal radical hysterectomy approach and yields a comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers, including radical hysterectomy for early cervical cancer. Young women desiring to bear children in the future may be candidates for fertility preservation options, and the radical trachelectomy operation has been described and performed with abdominal, vaginal, laparoscopic, and robotic techniques. There are a number of surgical options for the treatment of women with early cervical cancer. The feasibility and safety of some of these techniques have been well established, whereas for others, the oncological outcome data are only preliminary. The decision to use newer techniques should be directed by patient variables as well as the surgeon's training and competence with laparoscopy, robotics, or vaginal surgery.

Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle

Objective : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. Study design : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value < 0.05 was considered as significant. Results : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. Conclusions : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.

Initial laparoscopic access in postmenopausal women

Estrogen loss at menopause has a profound influence on skin, with postmenopausal atrophy and loss of tone and elasticity. Because more than 50% of major laparoscopic complications occur during initial entry under the abdominal skin, the efficacy and the safety of two laparoscopic access techniques were compared in postmenopausal women. One hundred eighty-six postmenopausal women underwent laparoscopic surgery for simple ovarian cysts: 89 were assigned to direct optical access (DOA), abdominal entry (group I), and 97 to the classic closed Veress needle approach, pneumoperitoneum, and trocar entry (group II). The following parameters were compared: time needed for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. Results were analyzed using SAS software, considering P value less than 0.05 as significant. No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques (P > 0.05), whereas time for abdominal entry was significantly reduced in the DOA group, as well as the occurrence of minor vascular injuries (P < 0.05). Results of this preliminary comparison on the DOA and the Veress methods, commonly used by gynecologists, suggest that the visual entry system offers a statistical advantage over the closed Veress needle approach, in terms of time saving and limiting minor vascular injuries, thus enabling a safe and fast visually guided entry in postmenopausal women.

Abdominal Access in Gynaecologic Laparoscopy: A Comparison Between Direct Optical and Open Access

More than 50% of major laparoscopic complications occur during the initial entry into the abdomen. We investigated the efficacy and the safety of two laparoscopic access techniques: the direct optical access (DOA) versus the classical open entry, as described by Hasson. Two hundred and two premenopausal women, homogeneous in age, parity, and body mass index undergoing laparoscopic surgery for simple ovarian cysts, were prospectively, randomly assigned to either open or DOA abdominal entry for laparoscopic surgery. The following parameters were compared: duration of access for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. The results were analyzed by using SAS software (SAS Institute, Inc., Cary, NC), considering a P-value of <0.05 as significant. No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques. However, time for establishment of abdominal entry was significantly reduced in the DOA group, as was the blood loss (P < 0.05). The results of this preliminary comparison on the DOA and the Hasson methods, commonly used by general surgeons and less frequently by gynecologists, suggest that the visual entry system confers a little statistical advantage over the traditional Hasson entry, in terms of safety, minimal time saving, and in reducing blood loss, allowing a safe, fast, visually guided entry.

An Innovative Method of Access for Laparoscopic Surgery

We illustrate different ways to access the abdominal cavity for laparoscopic surgery and complications that can result from that process. Furthermore, we present a novel FDA approved device named LapCap that uses suction to lift the abdominal wall and create a dome where the Veress needle can penetrate and create pneumoperitoneum at safe distance from retroperitoneal vascular structures. We demonstrate the technique in detail and report results from a clinical study. We think that the use of this device should avoid vascular injury from Veress needle insertion, increase the rate of success at first attempt and accelerate the process of abdominal entry.

Concurrent sigmoid volvulus and herniation through broad ligament defect during pregnancy: Case report and literature review

Sigmoid volvulus in pregnancy is a rare complication. The combination of sigmoid volvulus and sigmoid herniation through a broad ligament together with placental abruption in pregnancy is a most unusual obstetrical emergency. We report the case of a previously well 32-year-old Mexican woman who was transferred to our institution at 28 weeks gestation with threatened preterm labor. We considered the possibility of appendicitis. While awaiting a surgical consult, an emergency cesarean section was carried out for a prolonged deceleration of the fetal heart. A routine transverse suprapubic abdominal entry revealed a large loop of ischemic bowel. This was confirmed to be a sigmoid volvulus which had herniated through a left broad ligament defect. The deceleration was attributed to a large placental abruption. No previous case with a combination of a sigmoid volvulus and placental abruption was found in the literature.

New techniques in radical hysterectomy

To review the recent literature regarding modifications of abdominal radical hysterectomy as well as development of new approaches including laparoscopic, vaginal, and robotic radical hysterectomy. Nerve-sparing radical hysterectomy technique allows for significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates with absence of abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to a traditional abdominal radical hysterectomy approach that yields comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers and larger series describing successful treatment of cervical cancer with robotic radical hysterectomy are soon to be published. There are a number of approaches to performing radical hysterectomy. The feasibility and safety of these techniques have been well established. Preliminary oncologic outcome data are encouraging. The decision to utilize newer techniques depends on the patient and type of practice, as well as the surgeon's comfort level with laparoscopy, robotics, or vaginal surgery.

The CORONIS Trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial

BackgroundCaesarean section is one of the most commonly performed operations on women throughout the world. Rates have increased in recent years – about 20–25% in many developed countries. Rates in other parts of the world vary widely.A variety of surgical techniques for all elements of the caesarean section operation are in use. Many have not yet been rigorously evaluated in randomised controlled trials, and it is not known whether any are associated with better outcomes for women and babies. Because huge numbers of women undergo caesarean section, even small differences in post-operative morbidity rates between techniques could translate into improved health for substantial numbers of women, and significant cost savings.DesignCORONIS is a multicentre, fractional, factorial randomised controlled trial and will be conducted in centres in Argentina, Ghana, India, Kenya, Pakistan and Sudan.Women are eligible if they are undergoing their first or second caesarean section through a transverse abdominal incision.Five comparisons will be carried out in one trial, using a 2 × 2 × 2 × 2 × 2 fractional factorial design. This design has rarely been used, but is appropriate for the evaluation of several procedures which will be used together in clinical practice. The interventions are:• Blunt versus sharp abdominal entry• Exteriorisation of the uterus for repair versus intra-abdominal repair• Single versus double layer closure of the uterus• Closure versus non-closure of the peritoneum (pelvic and parietal)• Chromic catgut versus Polyglactin-910 for uterine repairThe primary outcome is death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures; or blood transfusion.The sample size required is 15,000 women in total; at least 7,586 women in each comparison.DiscussionImprovements in health from optimising caesarean section techniques are likely to be more significant in developing countries, because the rates of postoperative morbidity in these countries tend to be higher. More women could therefore benefit from improvements in techniques.Trial registrationThe CORONIS Trial is registered in the Current Controlled Trials registry. ISCRTN31089967.

Feasibility of the Maylard transverse incision for ovarian cancer cytoreductive surgery

The vast majority of abdominal incisions used in gynecologic surgery are either transverse or vertical midline. The advantages of a vertical midline incision are considered to be rapid abdominal entry and increased exposure to the abdomen and pelvis. The advantages of transverse incisions are purported to be cosmesis, decreased postoperative pain, decreased hernia rate, decreased abdominal adhesions, and fewer postoperative pulmonary complications. The Maylard incision is a transverse incision that combines the advantages of a transverse incision with improved pelvic and abdominal exposure. We wanted to evaluate the feasibility of the Maylard incision to provide adequate abdominal and pelvic exposure in women with advanced ovarian cancer undergoing cytoreductive surgery and to evaluate the extent of anterior abdominal wall adhesions at secondary cytoreductive surgery. In our experience, it appears that the Maylard incision provides adequate exposure to perform ovarian cytoreductive surgery. It appears that there are minimal anterior abdominal adhesions after cytoreductive surgery through a Maylard incision.

Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique

To date, endovascular repair of thoracic dissections is a reality, associated with acceptable morbidity and mortality. We present the case of a 72-year-old woman presenting a retrograde aortic dissection at the postoperative day 12, after an endovascular repair for a 60-mm thoracic dissecting aneurysm. Two years earlier, she had presented an uncomplicated thoracoabdominal type B aortic dissection between the isthmic aorta and the iliac bifurcation. Despite an acceptable blood pressure control, a 62-mm thoracic dissecting aneurysm was observed on the 24-month CT-scan. Due to a chronic obstructive pulmonary disease, we chose the endovascular approach to exclude the thoracic entry tear leading to the complete false lumen thrombosis around the endoprosthesis. However, the inferior part of the false lumen remained patent due to a second abdominal entry tear. The initial outcome was uneventful but the patient presented a sudden death syndrome twelve days after the endovascular repair. During the autopsy, we discovered an intrapericardial rupture of a retrograde dissection, starting at the level of the proximal bare spring of the endoprosthesis. We discuss some important technical details to improve the safety, and to reduce the risk of immediate or delayed complications.

Complications of laparoscopic surgery: How to avoid them and how to repair them

1Postoperative complications of thermal injury to bowel generally present on postoperative day aonebtwocthreedfour2Which is the most hazardous day to do outpatient laparoscopic surgery? aMondaybWednesdaycFridaydThursday3Urinary bladder injuries during laparoscopic-assisted vaginal hysterectomy and laparoscopic hysterectomy are report to be as high as: a0.5%b8%c2%d5%4What percentage of reported ureteral injuries is unrecognized during operation? a50%b30%c70%d40%5The safest means of abdominal entry is: aopen techniquebVeres needle insufflationcprimary trocar insertiondnone of the above6Major vascular injury can be avoided by using: apyramidal trocarbdilating trocarcoptical trocardnone of the above7Which can be a cause of electrosurgical injury during laparoscopy? aprobe couplingbinadvertent tissue contactcinsulation failuredcapacitative conductioneall of the above8Desiccation of tissue: ais the result of tissue dryingbmarkedly increases tissue impedancecstops the flow of electrons through tissuedall of the above9Secondary trocar insertion most commonly injures: asmall bowelbinferior epigastric vesselsccommon iliac arterydlarge boweleurinary bladder10Palmer’s point is in the: aright lower quadrantbleft lower quadrantcmidclavicular line below the ribsdsuprapubic area

Abdominal muscle flap repair for large defects of the diaphragm

Repair of a large diaphragmatic defect in congenital diaphragmatic hernia (CDH) and eventration of the diaphragm (DE) is difficult, especially when this is an unexpected finding at surgery. A patch of synthetic material may not be available at short notice, especially in developing countries. We describe the repair of nine such defects by using an abdominal muscle flap comprising the transversus abdominis and internal oblique muscles based on the intercostal and subcostal vessels. Although reports of similar flap repairs have been published in the literature [1-5], these employed a subcostal incision for abdominal entry, which we believe jeopardizes the flap's vascularity. Thus, we prefer to use an upper abdominal midline incision for abdominal entry in all cases of CDH and DE.

Laparoscopic repair of gastric perforation secondary to umbilical trocar insertion

A postmenopausal woman was scheduled to undergo laparoscopic treatment of an 8-cm simple ovarian cyst. During abdominal entry, umbilical trocar insertion caused a gastric perforation that was diagnosed immediately and repaired laparoscopically. Following completion of the procedure, the patient was observed for 24 hours with a nasogastric tube in place and was discharged to home on the second postoperative day without further complications. The possibility of gastric distension and perforation is almost always present during laparoscopic abdominal entry. When perforation occurs, repair can be accomplished safely by laparoscopy.

THE USE OF STAB INCISIONS FOR INSTRUMENT ACCESS IN LAPAROSCOPIC UROLOGICAL PROCEDURES

Traditional laparoscopic procedures use expensive cannulas to facilitate the insertion and removal of laparoscopic instruments. We report our experience with limited access stab incisions for the insertion of instruments into the peritoneal cavity during laparoscopic urological procedures to minimize the use of disposable cannulas. All patients undergoing laparoscopic urologic procedures using stab incisions, as performed by us, from November 1999 through March 2003 were included. Procedures included nephrectomy, partial nephrectomy, varicocelectomy, nephroureterectomy, orchiopexy and adrenal procedures. A single cannula was used for telescope access. In select cases additional cannulas were used for unique instruments or specimen manipulation/extraction. Abdominal wall stab incisions were used for the remaining instruments. Stab incisions were closed with a Steri-Strip (3M Healthcare, St. Paul, Minnesota) at the skin level only. A total of 53 procedures were performed during the study period. Pneumoperitoneum was maintained in all cases. There were no complications associated with the use of stab incisions. A total of 105 cannulas were saved using our technique. At a cost to the patient of dollars 140 per cannula the overall cost saving was dollars 14,700 with an average saving of dollars 277 per case. Laparoscopic urological procedures can be performed effectively and safely with stab incisions for instrument access. There are significant cost savings related to the elimination of cannulas. We believe that our technique of stab incisions for instrument access is equivalent to the traditional cannula approach and should be used when possible.

Trocarless safe abdominal entry for laparoscopy in women with previous abdominal surgery

Trocarless safe abdominal entry for laparoscopy in women with previous abdominal surgery

Mean Distance Between Primary Trocar Insertion Site and Major Retroperitoneal Vessels During Routine Laparoscopy

Major vascular injuries complicating laparoscopic operations are a source of significant morbidity and mortality. The goal of this study was to measure the distances between the anterior abdominal wall subumbilical trocar entry site and the retroperitoneal location(s) of the aorta, iliac vessels, and urinary bladder directly. Patients were measured during actual laparoscopic surgery in the lithotomy, or modified lithotomy position, level, and Trendelenburg positions. Patients were all divided according to body-mass index (BMI) and height. Significant differences between distances from the primary trocar insertion site to the aorta and the iliac vessels were observed. Similarly, significant differences in the thickness of the anterior abdominal wall were observed between three BMI groups. The use of reasonable precautions will enable the surgeon to avoid trocar damage to the great vessels located in the abdominal retroperitoneum.

Surgical techniques used during caesarean section operations: results of a national survey of practice in the UK

Objective: To determine what surgical techniques are used by obstetricians in the UK for elective and emergency caesarean section operations. Study design: A postal questionnaire to all members and fellows of the Royal College of Obstetricians and Gynaecologists (RCOG) resident in the UK, requesting information about the use of surgical techniques and antibiotic and anticoagulant prophylaxis for elective and emergency caesarean sections. Results: The response rate was 78.7%. A range of techniques was used for all procedures in caesarean section operations. Only a few techniques were used by more than 80% of obstetricians, including double layer closure of the uterus, use of prophylactic antibiotics and Pfannenstiel abdominal entry (for elective caesarean sections). There were few large differences in practice between elective and emergency caesarean sections. In emergency operations, more obstetricians use the Joel–Cohen method of abdominal entry (32.7 versus 16%) and more usually use prophylactic antibiotics and heparin (93.2 versus 85.4% and 45.8 versus 32.9%, respectively). Conclusions: There was wide variation in the surgical techniques used by obstetricians for caesarean section operations. There is an urgent need for future research to evaluate many aspects of caesarean section operations on substantive short- and long-term outcomes.

Voies d’abord de la cœlioscopie : cœlioscopie ouverte ou cœlioscopie fermée ? Attitude des CHU français

Standard technique of insufflation of the pneumoperitoneum includes the use of the Veress needle followed by the blind insertion of the umbilical trocar. To avoid blind trocar insertion, numerous techniques for the creation of the pneumoperitoneum have been reported: openlaparoscopy and microlaparoscopy are the two major alternative methods used in France. The aim of this study was to detennine the incidence of openlaparoscopy in the French departments of Gynecology of the University Hospitals. With this purpose, we send to each chief of the department of Gynecology in a University Hospital a simple questionnaire about the methods used in his division for the creation of pneumoperitoneum. Sixty-three chiefs of department have answered to the questionnaire. Thirteen (21 %) answered they only used conventional technique. Ten (16%) departments perfonned always openlaparoscopy, and 40 University Hospital mostly used conventional technique combined sometimes when the initial procedure of insufflation failed or seems to be too dangerous (Obesity, previous laparotomy... ). Five surgeons used a lateral rather than umbilical insertion for the openlaparoscopy in case of previous laparotomy. Fifteen departments used microlaparoscopy since 1995, and mostly since 1998. We conclude that no simple technique can claim to be overwhelmingly superior. It seems tous dangerous to impose or to condemn any methods. Keeping the choice of the technique, learning security and organizing the survey of our results remain our recommendations for the approaches of abdominal entry for laparoscopy.

Safe techniques for abdominal access and wound closure in laparoscopic surgery

Laparoscopic surgery requiring tissue morcellation was performed on 66 consecutive patients, using open laparoscopy for primary entry and the SECURE cone technique for accessing the port of mechanical morcellation. Thirty-six patients had laparoscopic myomectomy and 30 had supracervical laparoscopic hysterectomy. In all instances, abdominal entry was accomplished under visual control through a minilaparotomy incision, or using telescopic visualisation. The surgical wound was closed in two layers. The first layer consisted of the fascia at the primary site and the bulk of the abdominal wall at the morcellation site. The skin was approximated loosely. Although no complications were related to the open laparoscopy or SECURE cone techniques, most patients complained of mild to moderate postoperative discomfort related to the SECURE cone site. The discomfort was ameliorated when the bulk closure stitch was tied less tightly. Open laparoscopy and the SECURE cone methods represent safe techniques for primary and secondary abdominal access and wound closure in surgery.