Blind Insertion Research Articles

New Airway Management Device Offers Nothing New

The Airway Management Device (AMD) is similar to the laryngeal mask airway (LMA), but it has 2 silicone cuffs: The distal is inserted and inflated over the esophagus, and the larger, proximal cuff is inflated in the pharynx. The putative advantages of the AMD include blind insertion, need for minimal oral opening, and occlusion of the esophagus. In an observational study, …

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The LMA ‘ProSeal’—a laryngeal mask with an oesophageal vent

We describe a new laryngeal mask airway (LMA) that incorporates a second tube placed lateral to the airway tube and ending at the tip of the mask. The second tube is intended to separate the alimentary and respiratory tracts. It should permit access to or escape of fluids from the stomach and reduce the risks of gastric insufflation and pulmonary aspiration. It can also determine the correct positioning of the mask. A second posterior cuff is fitted to improve the seal. A preliminary crossover comparison with the standard mask in 30 adult female patients showed no differences in insertion, trauma or quality of airway. At 60 cm H2O intracuff pressure, the new LMA gave twice the seal pressure of the standard device (P < 0.0001) and permitted blind insertion of a gastric tube in all cases. It is concluded that the new device merits further study.

Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion

Objective: To determine the frequency of peritoneal and visceral adhesions to the umbilical region according to past surgical history and to estimate the risk of bowel injury with blind insertion of the principal trocar-cannula. Design: Prospective, unicentric study by a single operator. Setting: Clinique Saint-Sernin and Polyclinique de Bordeaux, Bordeaux, France. Patient(s): Eight hundred fourteen patients undergoing diagnostic or operative laparoscopy were classified into four groups based on their history of abdominal surgery: group I (n = 469), no previous abdominal surgery; group II (n = 125), prior laparoscopic surgery; group III (n = 131), previous laparotomy with a horizontal supra-pubic incision; group IV (n = 89), previous laparotomy with a midline incision. Intervention(s): Initial microlaparoscopy performed through the left upper quadrant of the abdomen, inspection of the anterior abdominal wall and particularly the umbilical area for the presence of adhesions. Patients who had adhesions were assessed as to whether or not they were at significant risk of injury from blind insertion of the principal trocar. Main Outcome Measure(s): Incidence of umbilical adhesions and the potential risk of bowel injury with blind insertion of the umbilical (principal) trocar. Result(s): Umbilical adhesions were found in 9.82% of the 814 cases. The rates of umbilical adhesions were as follows: group I, 0.68%; group II, 1.6%; group III, 19.8%; and group IV, 51.7%. Severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar in the four groups were 0.42%, 0.80%, 6.87%, and 31.46%, respectively. Conclusion(s): Women with previous laparotomy have a higher incidence of umbilical adhesions, especially in case of midline incision. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended for patients at risk for adhesions to reduce complications associated with insertion of the principal (umbilical) trocar.

T HE L ARYNGEAL T UBE : A N EW A DJUNCT FOR A IRWAY M ANAGEMENT

Introduction. A prototype of the laryngeal tube was tested for simple and reliable use for ventilation in a mannequin. One possible use of this tube will be the management of the difficult airway. In spite of blind insertion, an inadvertent tracheal positioning should not occur due to the form of the tube. A pharyngeal cuff provides a proximal seal of the airway, while an esophageal cuff seals the airway distally and prevents aspiration of gastric contents. A ventral opening between both cuffs is used for ventilation. Objective. To examine the reliability of the laryngeal tube for airway management in a mannequin. Methods. Fifty physicians and nurses were included in this study and inserted the laryngeal tube blindly during ten consecutive attempts in an advanced life support mannequin. All participants used the laryngeal tube for the first time. Results. During 500 insertions of the tube, correct placement and sufficient ventilation were achieved 478 times in the first attempt (95.6%); 18 times (3.6%), inflating the proximal balloon with an additional 50 mL of air led to sufficient ventilation. In four attempts (0.8%), sufficient ventilation was still not possible due to the tube's not being placed deep enough (according to the printed ring marks on the tube). In each case, the tube was placed correctly in the following attempt. Neither a tracheal intubation nor ventilation of the stomach could be observed. The average time for positioning the laryngeal tube was 27.15 seconds for all 500 attempts (average time of the 50 participants for the tenth attempt: 23.85 seconds). Conclusion. The laryngeal tube may be a fast, reliable, and easy device for airway management. Further research is necessary.

A Case of a Nasogastric Tube Knotting Around a Tracheal Tube: Detection and Management

A Case of a Nasogastric Tube Knotting Around a Tracheal Tube: Detection and Management

The role of microlaparoscopy for safer wall entry: incidence of umbilical adhesions according to past surgical history

ObjectiveTo determine the incidence of umbilical adhesions related to previous surgical history.DesignA prospective single‐centre study with a single operator.SettingClinique Saint‐Sernin and Polyclinique de Bordeaux, Bordeaux, France.Subjects900 patients undergoing diagnostic or operative laparoscopy, classified into four groups: group I, 419 patients with no previous surgical surgery (control group); group II, 140 patients with previous major operative laparoscopy; group III 145 patients with previous laparotomy with a horizontal suprapubic incision; group IV, 96 patients with a previous laparotomy with a midline incision.InterventionInspection of the umbilical area for the presence of adhesions, with a microlaparoscope passed through a Veress needle at Palmer's point.Main outcome measuresIncidence and severity of umbilical adhesions and their potential risk in case of blind insertion of the umbilical trocar.ResultsUmbilical adhesions were noticed in 9.77% of the 900 patients. The incidence was different in the four groups: group I, 0.77%; group II, 1.42%; group III, 21.37%; group IV, 53.12%. Severe adhesions, with a potential risk in case of blind insertion of the umbilical trocar, were encountered in 0.38%, 0.71%, 6.89% and 31.25%, respectively, in the patients in the four groups.ConclusionsWomen with previous laparotomy have a higher incidence of umbilical adhesions, especially in the case of midline incisions. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended in these high risk patients, in order to reduce complications of trocar insertion.

A New Technique for Performing Syed Template Interstitial Implants for Anterior Vaginal Tumors Using an Open Retropubic Approach

The Syed template (Alpha-Omega Services, Bellflower, CA) has been established as an advance in interstitial gynecologic brachytherapy. Unfortunately, enthusiasm for the technique is often tempered by certain tumor geometries which require blind insertion of the interstitial needles, potentially risking inaccurate placement of the radioactive sources and viscus perforation. These concerns arise particularly in the management of anterior vaginal tumors where difficulties in negotiating the pubic arch can prevent optimal needle placement. In answer to this problem, a technique utilizing an open retropubic approach for Syed template interstitial implants in anterior vaginal tumors under direct visualization is described. To date, six procedures have been performed. The disease entities include advanced cervical squamous cell carcinoma, clear cell carcinoma of the vagina, recurrent vaginal carcinoma, recurrent endometrial carcinoma, and urethral adenocarcinoma. Complete response was noted in five of six patients but persistent local control of disease was achieved in only one of five complete responses over a relatively short follow-up interval. Complications included paravaginal abscess (n= 1), postoperative deep venous thrombosis (n= 1), abdominal incision cellulitis (n= 1), and radiation enteritis (n= 1). An open retropubic approach allows direct visualization of the bladder and urethra during interstitial implantation of anterior vaginal malignancies and facilitates negotiation of the pubic arch. In our experience, this technique results in improved needle positioning and is thus intuitively likely to aid in avoiding injury to surrounding normal tissues. Additional accrual of a larger cohort will be necessary to arrive at any meaningful objective conclusions regarding the technique's benefit over current modalities.

Safe creation of pneumoperitoneum using an optical trocar.

The blind insertion of the Veress needle and the first trocar may cause serious complications. Therefore, many surgeons perform a minilaparotomy to safely position the first trocar. However, especially in obese patients, the dissection may be difficult and time consuming. As an alternative, optical trocars can be safely positioned under direct visualization. We report on our experience with the Optiview trocar in 200 patients and describe our preferred insertion technique. In our opinion, optical trocars are safe and easy to handle, offering several advantages over the use of the Veress needle and the minilaparotomy.

Routine use of open laparoscopy: 1,006 consecutive cases.

Blind insertion of the Veress needle and of the first trocar is a significant cause of laparoscopic surgery complications. Despite this risk, the closed technique is still more popular than the open one. The authors retrospectively evaluated 1006 consecutive laparoscopic operations in which Hasson's technique was routinely performed. The overall complication rate was 2.2%, but the vast majority of complications occurred during the first 50 cases (6% vs. 1.9%). They conclude that after a learning phase of about 50 cases, Hasson's technique is a quick and safe procedure.

Insertion of the Combitube airway with the cervical spine immobilised in a rigid cervical collar.

The Combitube is a twin lumen device designed to establish the airway after blind insertion. Under general anaesthesia a rigid cervical collar was used to immobilise the neck in 15 ASA 1 and 2 patients. Insertion of the Combitude airway was then attempted. In 10/15 (66%) patients, blind insertion was not possible. In 5/15 (33%) successful blind insertions the Combitube entered the oesophagus on each occasion. In 8/10 of the failures, re-insertion of the Combitude was attempted with the aid of a Macintosh laryngoscope. In 6/8 cases (75%) satisfactory placement was then possible with the Combitube again entering the oesophagus on each occasion. Ventilation was satisfactory in all patients when insertion was successful. Blood staining of the Combitube was present in 7/15 (47%) patients. The Combitude cannot be recommended for use in patients whose necks are immobilised in rigid cervical collars.

Establishing an ultrasound guided peripherally inserted central catheter (PICC) insertion service

Peripherally inserted central catheters (PICCs) are an increasingly used means of medium to long-term intravenous access. We have established an ultrasound (US) guided PICC insertion service at our institution that has largely replaced blind bedside insertions. One hundred and six PICCs were inserted in the upper arms of 89 patients, over a 6-month period with a 100% success rate. The technique for US guided vein puncture and guidewire insertion is described. Catheter related complications included infection (6 proven cases; 3.1 infections per 1000 catheter days); catheter blockage (7), breakage (8) and unintentional removal (5). Catheter blockage, breakage and partial unintentional removal are potentially remediable complications using guide-wire techniques under fluoroscopic guidance. The management of catheter related infection is discussed. We have encouraged early communication with our clinical colleagues in order to facilitate the management of such complications and minimize unnecessary catheter removal.

A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes.

BACKGROUND: In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions. RESULTS: Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram. CONCLUSIONS: Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

Major Vascular Injuries in Laparoscopy

ABSTRACT Laparoscopy is generally a safe and a well-tolerated procedure; however, complications and failures sometimes occur. The danger of damage to vascular structures and intrabdominal organs associated with blind insertion of the insufflation needle and trocars is always present. Safety shields on disposable cannulas do not prevent vascular accidents if proper insertion techniques are disregarded. If a retroperitoneal hematoma is observed, a laparotomy is required for its assessment. The cases of four patients who sustained vascular injuries during initial trocar insertion at laparoscopy are presented. Recommendations are made for the diagnosis, treatment, and—more importantly—for the prevention of vascular injuries at laparoscopy. (J GYNECOL SURG 14:123, 1998)

Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery.

Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used. A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases. The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma). The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.

The arthroscopic removal of loose bodies from the posterior compartments of the knee: a ‘two arthroscope technique’

Arthroscopic removal of loose bodies from the posterior compartments of the knee is often difficult. The problems of arthroscopic access are even greater in the osteoarthritic knee due to osteophytic encroachment around the intercondylar notch and synovial proliferation in the posterior compartments. Blind insertion of the obturator and sheath into the notch may not succeed and attempts to push the telescope risk damaging the instrument. A simple and safe technique of entering the posterior compartments under direct vision for removal of loose bodies is demonstrated. Two selective cases are presented to illustrate the value of the technique in the degenerate knee.

Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion.

The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to identify risk factors for complications. Data from a prospectively collected database of all laparoscopic operations performed at a major teaching hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to establish the pneumoperitoneum. Open laparoscopy with a Hasson's trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean +/- SD 2.99 +/- 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 patients undergoing laparoscopic surgery, 20 (3%) had developed complications specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n = 8, 2.0%), followed by umbilical hernias (n = 6, 1.5%) and umbilical wound infection (n = 5; 1.2%). The rate of penetrating injuries was 0.2% (n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0; p = 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.

Open versus closed establishment of pneumoperitoneum in laparoscopic surgery

Closed laparoscopy, employing a Veress needle and blind insertion of the first trocar, is favoured by most laparoscopic surgeons. The potential danger of this technique is the occurrence of visceral or vascular injury. Establishment of pneumoperitoneum by an open technique using a blunt-tipped trocar may be a safer alternative. Retrospective review of the literature and the authors' experience was used to compare closed and open laparoscopy. Data on closed laparoscopy in 489335 patients and on open laparoscopy in 12444 patients were culled. Rates of visceral and vascular injury were respectively 0.083 and 0.075 per cent after closed laparoscopy, and 0.048 per cent and zero after open laparoscopy. Mortality rates after closed and open laparoscopy were respectively 0.003 per cent and zero. Pearson chi 2 analysis demonstrated a statistically significant difference in terms of visceral and vascular injury between closed and open laparoscopy (P = 0.002); there was no such difference for mortality rates. Open establishment of pneumoperitoneum is advocated in laparoscopic surgery because it is safer than the closed method.

Successful intubation with the Combitube ® in acute asthmatic respiratory distress by a parkmedic

The Combitube ® is a relatively new device used for blind insertion emergency intubation. We report a case of successful Combitube ® treatment of an acute respiratory arrest secondary to an acute asthma exacerbation. An advanced EMT-II (National Park Service Parkmedic) utilized this device. Our review of the literature revealed no reported cases of an advanced EMT-II, nor any other cases, using the Combitube ® in asthma-related respiratory failure.

Laryngeal mask airway and the ASA difficult airway algorithm.

Laryngeal mask airway and the ASA difficult airway algorithm.