Direct Laparoscopic Vision Research Articles

New closure technique for lateral operative laparoscopic trocar sites

The reported frequency of incisional hernias, after operative gynecological laparoscopy, at extraumbilical trocar sites is one per 32 puncture sites created by a 12-mm trocar. A new closure technique of suturing with the Grice Needle (Ideas for Medicine, Inc., Clearwater, FL) before removing the trocars was utilized to close 80 lateral trocar sites (42 consecutive laparoscopic myomectomies). The trocar sizes in this study were 12 mm and 18 mm. This is the largest reported series of lateral trocar-site closures. No hematomas or bleeding or incisional hernias have resulted from use of this technique. This closure allows the surgeon to completely close both peritoneum and fascia, of the lateral trocar sites, under direct laparoscopic visualization without the loss of pneumoperitoneum or risk of inadvertent injury to the small bowel.

Fascial closure of laparoscopic port sites: A new technique

The laparoscopic operative procedure is not complete until the port sites are closed with a fascial suture. Herein, we report a simple new technique that uses a venous catheter for suture placement and direct laparoscopic visualization to secure the abdominal wall fascia and peritoneum.

Small bowel herniation after laparoscopically assisted vaginal hysterectomy

Laparoscopically assisted vaginal hysterectomies have been done with increasing frequency in the United States. To date, minimal complications have been noted with this procedure. The authors review a series of 90 individuals and note a three percent small bowel obstruction rate. This complication is more common in this group of patients than in patients having a standard abdominal hysterectomy. Since this operation has been commonly performed, it is often possible to convert an abdominal hysterectomy to a vaginal approach, this increase in complications is exceedingly high. The authors recommend closure of lateral abdominal wall port sites under direct laparoscopic visualization to prevent this serious complication.

A new technique of fascial closure for laparoscopic incisions.

The objective was to develop a technique and instrumentation for closure of 10-mm and larger laparoscopic incisions with a single instrument under direct laparoscopic vision, ensuring complete fascial and peritoneal closure. The Carter-Thomason Needle-Point Suture Passer functions as both a needle and a grasper, allowing for performance of laparoscopic directed fascial and peritoneal closure. It uses a 2.7-mm diameter grasping tool with a single-action jaw. The device introduces the suture through the muscle, fascia, and peritoneal layers under direct laparoscopic vision, drops the suture, picks it up at the opposite side of the opening, and is withdrawn grasping the suture. The surgeon completes the mass closure of the layers by tying the suture below the skin. Pneumoperitoneum is maintained. The closed peritoneal layer is viewed through the laparoscope, and palpation of the closure ensures that the fascial layer is completely occluded. The Carter-Thomason Needle-Point Suture Passer has been used as a single instrument for closure of 10-mm and larger incision sites in over 200 advanced laparoscopic procedures since March 1993. No incisional hernias or complications of the incisional site have occurred. This instrument and the technique have been used for ligation to control hemorrhage from a lacerated inferior epigastric vessel, with successful ligation obtained in less than 5 min. It also was used to pass suture to allow ligation of the infundibulopelvic ligament. This device provides complete and secure closure of operative incisions of 10 mm or larger, thereby reducing the risk of herniation during the postoperative recovery period.

Laparoscopic placement of ventriculoperitoneal shunts: preliminary report.

We used a laparoscopic technique for the percutaneous placement of the peritoneal end of cerebrospinal fluid shunts in adult patients with obstructive or normal-pressure hydrocephalus. Concurrent with the initial cranial part of the procedure, pneumoperitoneum is established in a routine fashion, and a video-laparoscope and grasping forceps are inserted into the peritoneal cavity. With use of a pacemaker introducer kit, the peritoneal catheter is placed percutaneously under direct laparoscopic vision through a small upper abdominal incision into the peritoneal cavity. At the completion of the procedure, the patency of the assembled shunt system can be verified by observing free flow of cerebrospinal fluid from the catheter tip as the valve is being pumped. We found that this technique is particularly useful in technically challenging cases--for example, those involving obese patients and those who have undergone multiple abdominal operations. No complications associated with the technique were encountered.

The frequency and management of uterine perforations during first-trimester abortions

The frequency and management of uterine perforation during first-trimester abortions remain a matter of continuing debate among gynecologists. The rate of uterine perforations was 1.3/1000 procedures (eight cases) in 6408 women undergoing first-trimester abortions at our clinic. We also performed 706 first-trimester abortions at the time of laparoscopic sterilization. Two perforations (2.8/1000 procedures) were reported before laparoscopy. Twelve (15.6/1000 procedures) unsuspected perforations were discovered during direct laparoscopic visualization. This represents a 19.8/1000 procedure rate of perforation (14 cases). All 22 patients with perforations were managed conservatively, and no immediate or late complications were noted. Our data suggest that the true incidence of uterine perforations is significantly underestimated and serious complications caused by perforations are rare. Conservative therapy is recommended rather than early surgical intervention.

Management of tubal pregnancy with methotrexate

Ten women with tubal ectopic pregnancy were treated by the injection of methotrexate into the gestational sac under direct laparoscopic vision followed by a course of intramuscular therapy including folinic acid rescue. One course of treatment induced resolution of the extrauterine pregnancy in eight women. Complete resolution (beta-hCG less than 10 miu/ml) was achieved within 6-47 days (mean 14.5 days). Serum beta-hCG levels started to decline 3.4 days from the beginning of therapy. Length of hospital stay was 5-11 days (mean 6.4 days). Treatment failed in two patients. One woman had a laparoscopic tubal clip sterilization concomitantly with methotrexate treatment. Tubal patency was demonstrated in all the other seven women (100%) tested subsequently. There is a need to establish criteria for patient selection before methotrexate becomes a routine treatment for tubal pregnancy.

Laparoscopic removal of an intra-uterine device.

Summary: A case is reported wherein a plastic contraceptive device was removed by means of the laparoscope and biopsy forceps from an extra‐uterine site in the pelvis. The removal under direct laparoscopic vision was both rapid and simple.