Entry-related Complications Research Articles

Laparoscopic entry in obese patients: Jain point

Objectives: The study aims to analyze the safety of a novel entry port, the Jain Point for first blind laparoscopic entry port in obese patients, which is non umbilical in position, located in mid abdomen, applicable in patients with or without previous surgery. Methods: The study was conducted at an advanced laparoscopy center between January 2011 to December 2023. Total 9715 patients underwent laparoscopy and out of these, 1362 were selected and categorized as per WHO criteria for obesity. The selection criteria were solely based on BMI. All first blind entries were made by Jain point. The entry related complications were compared with other conventional techniques. Results: In the study period, 1362 obese patients were operated. Time spent in establishing the pneumoperitoneum and trocar entry was comparable to other conventional approaches with a short learning curve. Major complications in the form of MRV (major retroperitoneal vessel) injury was not noted in our series. No injury to stomach and any other viscera noted. Minor complications in the form of prepertioneal insufflation and omental emphysema in 2.7% and failed entry were noted in 1% cases. All surgeries were completed laparoscopically and majority of patients were discharged in 24 to 48 hours. Conclusions: Keeping in context the safety of non umbilical entry ports, this study proposes Jain Point a, lateral, non-umbilical, primary blind entry port, as a viable option in obese patients, with or without previous surgeries.

Single-port laparoscopic-assisted abdominal cryptorchidectomy in 14 dogs.

To describe a modified laparoscopic-assisted cryptorchidectomy technique in dogs using a single-port endoscope and evaluate clinical outcome in abdominal cryptorchid dogs that underwent the procedure. Prospective case series. A total of 14 client-owned dogs (19 abdominal cryptorchid testes). Dogs scheduled for laparoscopic cryptorchidectomy between January 2019 and April 2022 were enrolled in the study. The dogs underwent single-port laparoscopic-assisted cryptorchidectomy (SP-LAC) performed by a single surgeon using a 10-mm single-port endoscope placed in the midline immediately cranial to the prepuce. The abdominal testis was endoscopically located and grasped, the cannula was retracted, the capnoperitoneum was reversed to allow exteriorization of the testis, and the spermatic cord was ligated extracorporeally. Median age was 13 months (range, 7-29 months) and median bodyweight was 23.0 kg (range, 2.2-55.0 kg). Nine of 14 dogs had unilateral abdominal cryptorchidism (7 right-sided and 2 left-sided) and 5/14 dogs had bilateral abdominal cryptorchidism. Median surgical time for unilateral abdominal cryptorchidectomy was 17 min (range, 14-21 min) and for bilateral abdominal cryptorchidectomy 27 min (range, 23-55 min). Ten dogs had additional surgical procedures performed concurrently with SP-LAC. One major intraoperative complication (testicular artery hemorrhage) occurred that required emergency conversion and two minor entry-related complications were observed. The SP-LAC procedure enabled removal of abdominal testes and was associated with a low morbidity. The SP-LAC procedure can be performed by a single surgeon and represents a less invasive alternative to multi-port laparoscopic-assisted or single-port multi-access laparoscopic cryptorchidectomy techniques.

Jain point: an alternate laparoscopic non-umbilical first blind entry port to avoid vessel, viscera, adhesions and bowel (VVAB)

The Jain point entry is based on the concept of non-umbilical entry to avoid sudden catastrophic injury to major retroperitoneal vessels, viscera, adhesions and bowel which could happen before the start of procedure by blind umbilical entry. To study the safety and efficacy of a novel first non-umbilical blind entry port. Tertiary referral centre for advanced laparoscopic surgeries with active training and fellowship programs. A large retrospective study of 7802 cases done at Vardhman Infertility & Laparoscopy Centre from January 2011 to December 2020. In all cases, first blind entry was by veress needle and 5 mm trocar and telescope through a non-umbilical port, The Jain point, irrespective of BMI, large masses, lax abdomen, previous surgery and complex situations. Patients’ demographic profile, types of surgeries performed and entry-related complications were recorded and analysed. Mean age of patients was 33 years with BMI ranging from 12.66 to 54.41 kg/m2. Thus, Jain point can be applicable for all ranges of BMI, all types of surgeries from simple to complex and large masses. Entry related minor complications were in 3.4% cases while major complication involving bowel occurred in one case. No case of injury to major retro-peritoneal vessel was seen. Jain point entry is a novel, first blind 5 mm non-umbilical, entry technique in a variety of surgeries and previous scars and patients with wide range of BMI. It has a short learning curve and continues as main ergonomic working port.

Closed entry technique for the laparoscopic management of adnexal mass during pregnancy

Management of adnexal masses during pregnancy is challenging for most gynecologists. When surgery is needed, a minimally invasive approach should be preferred. The aim of this study was to evaluate the safety and feasibility of the closed entry technique for laparoscopic management of adnexal masses during pregnancy. We reviewed clinical records and videos of laparoscopic procedures performed during pregnancy. Seventeen pregnant patients with diagnosis of adnexal mass that required surgery underwent laparoscopic surgery using the closed entry or Veress technique. We searched for complications related to surgery and obstetrical and perinatal outcomes. Median gestational age at the moment of surgery was 17 weeks (range, 6–30+4 weeks). A total of 18 interventions were performed: 12 salpingo-oophorectomies, 3 cystectomies, 1 salpingectomy, and 2 ovarian detorsions. There were no major operative or entry-related complications. Median hospital stay was 2 days (range, 1–5). Perinatal outcomes were as follows: four preterm births (all of them induced), nine full-term deliveries, one early pregnancy loss at 7 weeks, one miscarriage at 18 weeks, and two ongoing uncomplicated pregnancies. Laparoscopic approach using closed entry technique with an individual selection of the puncture site is safe in the management of adnexal masses that require surgery during pregnancy. In our experience, the Veress technique is more versatile as it gives the surgeon more freedom to choose the location of the first trocar in patients with important space limitations due to the size of the adnexal mass and/or the enlarged gravid uterus.

Safe Laparoscopic Entry Technique – A Follow-Up Retrospective Review of the Last 2000 Cases

To review all gynecologic laparoscopic cases performed by the study investigators from 1996 – 2010 to identify entry-related complications. The abdominal entry technique is a modified direct entry technique with the Veress needle based on previously studied principles of anatomy and physics encountered during GYN laparoscopy. The technique employed had been previously published by the senior authors, and is the primary method used.

Hasson's cut-down technique through Palmer's point

Response Letter to Article: Direct optical entry through Palmer's point: A new technique for those at risk of entry-related trauma at laparoscopy Aust TR, Kayani SI, Rowlands DJ Gynecol Surg 2010; 7:315–317 We read with interest the recent report of an alternative laparoscopic entry method proposed by Aust et al. for those gynaecological patients who are at risk of bowel injury as a result of periumbilical adhesions, as well as very thin or morbidly obese patients who require an alternative entry site [1]. The authors have described a new technique which uses a direct optical entry method at Palmer's point (3 cm below the left costal margin in the midclavicular line) [2]. By doing this, one is allowed a visual inspection of the umbilicus and ensuing adhesiolysis to allow subsequent insertion of an umbilical port under direct vision. The authors have performed this technique on 15 patients and reported no entry-related complications. Periumbilical adhesions were seen in 12 of the 15 patients.

A randomized trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women.

Objective:To perform hysteroscopy the cervix needs to be dilated and in nullipara and postmenopausal women this is sometimes difficult. Well-known, entry-related complications during hysteroscopy include cervical tear, creation of false tract, bleeding, uterine perforation, scarring, and subsequent anatomical stenosis.Materials and Methods:This study was done to investigate the priming effect of vaginal misoprostol on cervical dilatation in postmenopausal women, before hysteroscopy, to prevent such complications. Two hundred micrograms of misoprostol was inserted into the vagina at least 12 hours before the procedure and the control group did not receive any cervical priming agent. Pre-procedural dilatation, additional dilatation required, and time taken for dilatation was noted in each case.Observations:The study showed a significant difference between the study group (7.7 ± 1.7 mm) and the control group (4.5 ± 1.8 mm) in terms of pre-procedural cervical width and the number of women requiring a dditional dilatation (7 / 25 versus 22 / 25), and hence, the time required for dilatation (4.7 ± 8 seconds versus 20.6 ± 9.3 seconds).Conclusion:The pre-procedural cervical width was significantly more in the study group as compared to that in the control group. We found significant differences between the study and control groups with respect to the number of women who required cervical dilatation. To conclude, this study helps derive a conclusion that vaginal misoprostol as a cervical priming agent in postmenopausal women appears to be safe, effective, and inexpensive, with mild side effects.

Are we underutilizing Palmer's point entry in gynecologic laparoscopy?

To report our experience using Palmer's point entry in women undergoing gynecologic laparoscopic surgery. Retrospective observational study. University teaching hospital, London, United Kingdom. We reviewed all patients who underwent laparoscopic gynecologic surgery under the care of the senior author between January 1, 2005, and December 31, 2008. Gynecologic laparoscopic surgery. Indications, incidence, success, and complications of using Palmer's entry. Three hundred eighty-five patients underwent laparoscopic surgery. We used umbilical entry in 249 (64.6%) and Palmer's entry in 136 (35.4%). In almost three fourths of cases, the indications for using Palmer's point were previous laparotomy or the presence of large uterine fibroids. The next most common reasons for choosing Palmer's point were known documentation of intra-abdominal adhesions from prior laparoscopies, large ovarian cysts, and hernias or hernia repairs. Entry via Palmer's point was successful in all but two cases (98.5%), and there were no entry-related complications. Our experience shows that laparoscopic entry using the left upper quadrant is safe with a low failure rate. Because the vast majority of gynecologic laparoscopies are done using subumbilical entry, it seems that Palmer's entry is underused by many gynecologists, despite it being safer in patients at risk of underlying adhesions and more appropriate in the presence of a large pelvic mass or a nearby hernia.

Initial Laparoscopic Access in Postmenopausal Women: A Preliminary Prospective Study

Hypoestrogenism in postmenopausal women results in skin atrophy with a decrease in both elasticity and skin thickness. The fragility of the skin in aging women may be responsible for the reported 50% or more increase in major laparoscopic complications during the initial entry into the female abdomen. Several first-entry techniques in laparoscopy have been investigated to minimize entry-related complications. The Veress needle approach is the standard method used by most gynecologists. A promising new method is the direct optical access (DOA) which uses optically-guided trocars to provide visual guidance during entry. These 2 techniques have not been compared. The aim of this prospective randomized study was to evaluate the efficacy and safety of these 2 methods in postmenopausal women. The study was conducted at multiple European gynecology centers between 2004 and 2008. A total of 186 postmenopausal women scheduled to undergo laparoscopy for simple, persistent postmenopausal ovarian cysts were randomized to 2 groups: group I (n = 89) was assigned to surgical entry using DOA, and group 2 (n = 97) was assigned to entry using the Veress needle method. The 2 procedures were compared for the following parameters: the time needed for achieve adequate abdominal access, the occurrence of major and minor vascular and bowel injuries, and blood loss during laparoscopic access. The time needed to establish adequate abdominal access was significantly reduced in the DOA access group compared to the Veress group (65.7 ± 11.9 vs. 192.8 ± 5.6 minutes; P < 0.0001), but there were no significant differences between the two groups in the occurrence of major vascular and/or bowel injuries (P = NS). Although fewer minor vascular injuries were found with DOA method than the Veress technique (1 versus 3), the difference was not statistically significant. The findings of this small preliminary study suggest that use of the DOA technique may be a safe and less time-consuming approach to abdominal entry in postmenopausal women and may avoid the risks of blind access laparoscopy.

Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications

This study aimed to establish criteria for safe laparoscopic entry through a systematic literature search and evidence-based medicine appraisal, to determine surgeon preferences for laparoscopic entry in the United Kingdom, and to appraise the medicolegal ramifications of complications arising from laparoscopic entry. A systematic literature search of MEDLINE and EMBASE (1996-2007) was performed as well as a national surgeon survey by questionnaire (May-December 2006). Laparoscopic entry criteria involving 10 steps were established based on the systematic literature search and evidence-based critical appraisal. The national survey had 226 respondents, with the majority aware of the Middlesbrough consensus or Royal College of Obstetricians and Gynaecologists [RCOG]-sourced guidance. There was considerable variation in preferred laparoscopic entry techniques. Currently, there is clear judicial guidance on the medicolegal stance toward laparoscopic entry-related complications. Despite widespread awareness of laparoscopic entry guidelines, there remains considerable variation in the techniques adopted in clinical practice. Unless practice concurs with recommended guidance, women undergoing laparoscopy will be exposed to increased unnecessary operative risk. Laparoscopic entry-related injury in an uncomplicated woman is considered negligent practice according to UK legal case law.

Medical liability insurance claims on entry-related complications in laparoscopy

Installation of the pneumoperitoneum is an essential part of laparoscopic surgery. Creation can be performed by either the open or a closed technique. The aim of this study was to assess the number of and contributing factors to entry-related complications in medical liability insurance claims in The Netherlands. A retrospective chart review was performed, including all malpractice claims filed at MediRisk, which is presently the largest medical liability mutual insurance company for institutions, mainly hospitals, in healthcare in The Netherlands. From January 1993 to December 2005, 41 claims were identified as entry-related complications which comprised 18% of all laparoscopy-related complications leading to claims. Most were young (median age = 35 years) female patients who had routine, nonadvanced, laparoscopic procedures planned as short-stay or day-care procedures. The claims were equally divided between general surgery (n = 20) and gynecology (n = 21). A total of 51 structures were injured. There were 18 vascular structure injuries, 30 bowel injuries, and three other injuries. An open entry technique was used in only two (5%) patients. Vascular injury was exclusively associated with closed entry. In only 19 (46%) patients the entry-related complication was diagnosed peroperatively, consisting of 70% of the vascular and 25% of the bowel injuries. Twenty-six patients (64%) were admitted to the intensive care unit for a median of five days. There was no mortality. Besides conversion, the majority of the patients filed a claim to compensate for a longer hospital stay and related costs. A payment was made in 17 (57%) of the 30 settled claims. Medical liability claims concerning laparoscopic entry-related complications comprised a fifth of all laparoscopy-related claims. Claims concerning entry-related complications occurred in young patients who had routine, nonadvanced procedures. In the investigated cases most claims involved the closed-entry technique.

The ABCs of a safer laparoscopic entry

It is well known that at least 50% of laparoscopic complications occur during the initial entry into the abdomen regardless of the method used. There is evidence that most gynecologists practice the "classic" or closed laparoscopic entry. There is no evidence that the closed entry is more or less dangerous than the other existing methods of entry. Entry-related complications have been minimized by the following three steps: low initial Veres intraperitoneal pressure indicating correct placement of the Veres needle; transient high-pressure pneumoperitoneum before primary trocar/cannula insertion; and visual entry with the Ternamian cannula. Following the above steps, no entry complications have been encountered by the author in more than 3000 consecutive laparoscopies.

Laparoscopic entry techniques: a protocol for daily gynaecological practice in The Netherlands

This Dutch model protocol aims to formulate recommendations on insertion of laparoscopic instruments in order to reduce entry-related complications. It was written on behalf of the Dutch Society of Gynaecological Endoscopy and Minimal Invasive Surgery and serves as guidance to safe entry in laparoscopy for the Dutch gynaecologist in daily practice. It was translated and made suitable for publication in English. Despite the variety of methods described for creating pneumoperitoneum, no one single method can claim to be fundamentally superior to another. The practising laparoscopist should be familiar with at least more than one entry technique.

Complications of laparoscopy: An inquiry about closed- versus open-entry technique

Objective The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands. Study design Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected. Results Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively ( P<.001). Significantly more visceral lesions were found ( P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively. Conclusion Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.