Verres Needle Research Articles

Veres needle.

After its invention in 1936, the Veres needle lay dormant for many years. The video computer chip was developed in 1986, which allowed projection of the laparoscopic image on to a screen1. This led to the implementation of laparoscopic surgery through the 1990s, and the need for methods to establish pneumoperitoneum revived the Veres needle. Today, it is in widespread use2. János Veres (Fig. 1) was born in Kismajtény, Hungary, in 1903. He earned his medical degree at the University of Debrecen in 1927. He trained in internal medicine and was head of the Department of Pulmonology and Internal Medicine at Kapuvár Hospital in Debrecen from 1932 to 1955. Tuberculosis was widespread at the time, and one of the first successful treatments involved puncture of the pleural cavity, creating a pneumothorax and collapsing the lung. The risk of lung injury inspired Dr Veres to invent his instrument. He published in Hungarian in 19363 after nearly 1000 successful procedures, and later in German4. In publications, János Veres’ surname is presented with either a single or a double s. The correct spelling is with a single s, and so the instrument should rightly be called a Veres needle5.

A New Laparoscopic Entry Point in Patients With Previous Laparotomy: A Prospective Comparative Study.

Intraperitoneal access and establishing pneumoperitoneum for laparoscopy is a critical step especially in patients who underwent previous laparotomy due to the higher risk of visceral or vascular injuries. In this study, we propose a new entry point for safe laparoscopic access in cases having previous laparotomy. This is a prospective controlled randomized trial conducted between January 2016 and January 2022 in Ain Shams University Hospitals. It included 232 patients who underwent laparoscopic procedures after previous laparotomy. They were randomly divided into 2 equal groups. In group 1, laparoscopic access was carried out by an optical trocar through the new point situated in the subxiphoid region 1cm below the costal margin and centered 2.5cm from the midline on either side. In group 2, laparoscopic access was performed by an optical subumbilical trocar after Verres needle insufflation in Palmer point. The primary end points were success and safety of entry, measured by the number of entry attempts and the incidence of bowel and vascular injuries. The secondary end point was the entry time. In group 1, safe entry into the abdomen was achieved without visceral or vascular injury. In the 3 cases, minor liver injuries occurred. In group 2, 2 major vascular injuries and 5 bowel injuries occurred. There was a significant difference in procedure time (55±7.2s in group 1 vs. 192±11.6s in group 2). The suggested entry point is fast, safe, and reliable in patients having previous laparotomy.

Prospective Observational Study of Comparison Between Direct and High-Pressure Primary Trocar Entry in Gynaecological Laparoscopy in Teaching Hospital.

Laparoscopic port entry is crucial and vital step in any laparoscopic surgery. As laparoscopy is widely used, complications related to it are also increasing which are not seen in conventional laparotomy. The present study was undertaken to compare the ease of primary trocar entry after pneumoperitoneum at 20mmHg pressure and direct trocar entry without pneumoperitoneum. Total 100 nulliparous patients who presented for elective gynaecologic laparoscopic surgery were enrolled for the study. In operating theatre, randomization of patients was done using a sealed envelope technique which divides patients into two equal groups and assigned as either low-pressure group or high-pressure group. Verres needle insertion and trocar entry was done by fellowship trainee in laparoscopy assisted by senior laparoscopy surgeon. In high-pressure group we had trocar entry in first attempt in 80% of patient, second attempt in 20% where as in direct trocar entry group required first attempt in 88%, second attempt in 10% and third attempt in 2%. Time taken for trocar entry between two groups was significantly different requiring 4.42 ± 0.55min for high pressure and 1.2 ± 0.28min for direct trocar entry. The study concluded that high-pressure trocar entry requires more time; require less attempts, easier and surgeon will be more comfortable in repeating the same technique than direct trocar entry.

Method for safe Verres needle entry at the umbilicus, with modification for first trocar entry to reduce the complication rate of first entry.

Background:Initial intraperitoneal access and first trocar entry are responsible for nearly half of all complications of laparoscopic surgery. The purpose of this article is to detail our method of initial intraperitoneal access with Veress needle and first trocar at the umbilicus used over the past 28 years.Patients and Methods:Since 1990, a single surgeon performed laparoscopic surgery in 7600 patients. From 1992 onward, 6975 patients underwent laparoscopic surgery. On assessment, 739 cases (10.6%) were found unsuitable for Veress needle entry at the umbilicus. The remaining, 6236, patients form the study group for this article. Every patient was operated in the identical, repetitive manner. Every detail was considered important. The method of the first trocar entry is modified to minimise complications of this manoeuvre.Results:The average time from cleaning umbilicus again to Veress needle tip in peritoneum was 1 min 40 s (25 s–7 min). Out of the 4228 patients in whom no adhesions were observed at first trocar entry (Group 1), the Veress needle insertion was successful at first attempt in 3829 (90.5%) patients, at second attempt in 322 (7.6%) and at third attempt in 30 (0.7%). In the 2008 patients with significant adhesions observed after first trocar entry (Group 2), successful insertion of the Veress needle was achieved at first attempt in 1700 (84.6%) patients, at second attempt in 182 (9%) and at third attempt in 19 (0.9%). In this group, there was one bowel injury (0.05%) and 3 (0.15%) minor vascular injuries. There was no mortality in either group. In the overall series, the Veress needle was successfully introduced in 6082 of the 6236 patients (97.5%) and 154 patients (2.4%) failed Veress needle entry. The incidence of bowel injury in the series was 0.016% and that of minor vascular injuries was 0.048%.Conclusions:Initial intraperitoneal access must be performed with utmost caution after adequate training and proctorship. This paper stresses with meticulous attention to every detail, this safe, method of initial intraperitoneal access leads to low complication rates.

The effect of laparoscopic pre- and postconditioning on pneumoperitoneum induced injury of the peritoneum.

Pneumoperitoneum, widely used in laparoscopic surgery increases the intraabdominal pressure, leading to hypoperfusion of the abdominal organs, and promoting the buildup of reactive oxygen species(ROS) and inflammatory cytokines which in turn impairs the body postoperatively. Aim of our investigation was to evaluate the potential protective effects of short ischemic episodes on ischemic damages. 70 Wistar rats were used, divided into 7 groups: 1st group sham, 2nd group pneumoperitoneum with 5 mmHg, 3rd group preconditioning with 5 mmHg, 4th group: postconditioning with 5 mmHg, 5th group pneumoperitoneum with 10 mmHg, 6th group: preconditioning with 10 mmHg, 7th group postconditioning with 10 mmHg. Pneumoperitoneum was created by Veres needle. Oxidative stress parameters: malondialdehyde (MDA) concentration, reduced glutathione (GSH), sulfhydril (SH-), myeloperoxidase (MPO) levels and superoxide-dismutase (SOD) activity were measured. We measured TNF-α and IL-6 concentrations. We monitored the activation of anti- and proapoptotic common signaling pathways (bax, bcl-2, p53) during the early phase of reperfusion. Histology was made from kidney samples. GSH concentrations were significantly reduced, MDA concentrations were significantly higher in each group compared to the Sham. SOD enzyme: a pressure of 10 mmHg elicited significantly greater damage than 5 mmHg. There was a significantly higher SOD activity in group 10 mmHg IPC compared to 10 mmHg. We found that the expression of bax was considerably higher in the none conditioned groups. Noticeably higher expression of anti-apoptotic bcl-2 level was measured in 10 mmHg IPC and 10 mmHg IPoC groups. In case of p53 expression: significant decrease could be seen in groups 10 mmHg IPC and 10 mmHg IPoC compared to the 10 mmHg group. Based on our results, the elevated intraabdominal pressure due to pneumoperitoneum induces oxidative stress, which is dependent on the applied pressure. Mostly precondiotioning - but also postconditioning - reduces surgical stress following laparoscopic procedures. In order to explore its mechanism it requires further investigations.

The primary trocar insertion in laparoscopic cholecystectomy after cesarean section scar: A comparative study between Hasson Technique and Verres Needle

The primary trocar insertion in laparoscopic cholecystectomy after cesarean section scar: A comparative study between Hasson Technique and Verres Needle

Laparoscopic Entry via the DE-ALWIS METHOD

Despite the rapid advances in laparoscopic surgery in the past 2 decades the initial entry still accounts for approximately 40% to 50% of laparoscopic complications and should be considered the most dangerous step of a laparoscopic procedure. In this review, the authors share a technique for initial umbilical entry, and provide alternative entry sites in cases where umbilical entry is comtraindicated. Rev Obstet Gynecol. 2009; 2(3):193-198 doi; 10.3909/riog0088. Laparoscopy for diagnostic purposes to a modality for minor and major surgical procedures, had been advancing rapidly over the last 3 decades. The initial entry still accounts for about 40-50% of laparoscopic complications and is the most dangerous step of this surgical procedure [1, 2]. Laparoscopic entry using a veres needle followed by a blind insertion of a sharp trocar is the common method used by gynaecologists [3-5]. There is no concensious as to which laparascopic entry is superior and the common recommendation is use the entry methods with which the surgeons feel comfortable [6]. Umbilical entry is not suitable in certain instances, such as previous midline abdominal incision, previous umbilical hernia surgery, previous pelvic peritonitis and so forth, due to the presence of pelvic adhesions. An open surgery does not guarantee against a visceral injury [7].

3175 Gynecological Intervention Leading to Multiple Gastrointestinal Events

INTRODUCTION: This study follows a case of a right ovarian cystectomy gone wrong. Ninety studies published between 1972-2014, representing 474,063 gynecologic laparoscopies. Six hundred and four bowel injuries were reported for an incidence of 1 in 769. The rate of bowel injuries was dependent on the type of procedure. The small bowel happens to be the most frequently injured in the gastrointestinal tract, with about 166 of 354 (45%) of the cases. The majority of these injuries were due to veres needle or trocar placement with about 201 of 366 (55%) (Llarena N.C et al 2015). This review is to evaluate the gastrointestinal complications that accompanied a trocar induced injury during a gynecological procedure. CASE DESCRIPTION/METHODS: A 28-year-old female presented to the ED with septic shock. History obtained from relative stated the patient had a right ovarian cystectomy performed a week before ED visit. Post-op, the patient had increasing abdominal pain which worsened until EMS was called. An abdominal ultrasound showed central vowel dilation predominantly in the small bowel in correlation with ileus. CT abdomen showed free air throughout the abdomen large amount of fluid including the edge of the liver with infarcts in the Liver and spleen. Comprehensive Metabolic Panel showed AST- 5974, ALT- 2472, LDH- 1195 Total bilirubin- 1.5, direct bilirubin- 1.91, Amylase- 155. Complete Blood Count with WBC- 20.70. Coagulation with INR- 2.39, Fibrin > 700. The above test after consultation with specialists indicated Ischemic hepatitis “shock liver” with very strong indications due to hepatic infarction as a result of hemodynamic instability (Friedman L.S et al 2018). Other complications included small bowel ileus, peritonitis due to perforation and systemic involvement as a result of shock. DISCUSSION: In conclusion, gastrointestinal complications are rare after a laparoscopic procedure. Irrespective of their frequency can result in mortality. The best approach lies in the surgical technique and experience. Early recognition is the best way to avoid further complications as a delay could result in sepsis and untimely death. In an event of a suspected gastrointestinal injury, general surgical consultation should be sought, and a management strategy implemented. (Karadag M.A et al 2015).

Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis: A Combined Cystoscopic and Laparoscopic approach

Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis: A Combined Cystoscopic and Laparoscopic approach

Major vascular injury during laparoscopy

Major Vascular injury during laparoscopy is most deadly complication of laparoscopy. This report is review major vascular injuries based on surgeon’s relation and literature. The incidence of MVI is 0,04–0,1%. Extremely important is to learn proper technique of insuflation. According to patient’s physique surgeon should consider best technique of insuflation, take caution against slim people, and induct implements with proper angle. We should avoid excesive force during trocar and Verres’s needle insertion, we also should avoid redundant movement after Verres needle is inserted in abdomen cavity. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is routinely recomended. Major vascular injury is seriously underestimated problem of laparoscopic operations.

Major vascular injury during laparoscopy.

Major Vascular injury during laparoscopy is most deadly complication of laparoscopy. This report is review major vascular injuries based on surgeon's relation and literature. The incidence of MVI is 0,04-0,1%. Extremely important is to learn proper technique of insuflation. According to patient's physique surgeon should consider best technique of insuflation, take caution against slim people, and induct implements with proper angle. We should avoid excesive force during trocar and Verres's needle insertion, we also should avoid redundant movement after Verres needle is inserted in abdomen cavity. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is routinely recomended. Major vascular injury is seriously underestimated problem of laparoscopic operations.

COMPARISON OF A NEW VERESS NEEDLE ENTRY METHOD AND CLASSIC VERESS NEEDLE ENTRY METHOD IN GYNECOLOGIC LAPAROSCOPY: A PROSPECTIVE RANDOMIZED STUDY

Background: To compare cranial 15º angulation of Veres needle to classic Veress needle entry in closed laparoscopic entry in obese patients.
 Method: Patients with BMI index>30 were divided into two groups. Initial entry into the abdomen in Group 1 (n=29) was performed with the intraumbilical insertion of Veress needle in 90o angle relative to the horizontal plane. In Group 2 (n=31) the Veress needle was placed intraumbilically in a cranial direction, the tip of the needle towards the thoracic cavity, with an angle of 15o to the horizontal plane. Two groups were compared with respect of the operative outcomes.
 Results: In Group 2, the mean number of Veress needle entries attempt was significantly lower than Group 1 (p=0.01). Time to insertion of the Veress needle was found to be significantly shorter in Group 2 than in Group 1 (p<0.001). While entry failure occurred in 3 patients in Group 1 (10.3%), no failures were monitored in any patients in Group 2 (p= 0.01). Complication rate was significantly lower in Group 2 than in Group 1 (p= 0.03).
 Conclusion: Placement of Veress needle intraumbilically in a cranial direction at 15°angle to the horizontal plane increases entry success and reduces complications.

Laparoscopic Management of Inferior epigastric vessel injury

A 18 years young adult female diagnosed as left ovarian dermoid cyst underwent laparoscopic ovarian cystectomy. There was evidence of a hematoma at the Verres needle entry at Palmers point which slowly got extended to the midline. Local cauterization with bipolar current and a local stitch could not arrest the hemorrhage. Hence the epigastric vessel was traced to the origin and a haemostatic intracorporeal polygalactin suture of no 1 polygalactin 910 was taken at the reflection of the vessels over the anterior abdominal wall and the hemorrhage was controlled. The patient received antibiotics analgesics antacids and low molecular weight heparin and made an uneventful recovery. This technique of tackling inferior epigastric vessel bleeds proves to be helpful in refractory cases of inferior epigastric vessel bleeding during laparoscopy

Initial experience with single-port robotic hysterectomy.

ABSTRACTObjectiveThis article presents the first series of robotic single-port hysterectomy cases performed at a hospital in Brazil.MethodsFrom November 2014 to October 2016, 11 patients were indicated to undergo, and nine of them were submitted to single-port hysterectomy using da Vinci Single-Site® platform. However, in two patients, due to multiple previous abdominal surgeries, large uterine volume, and/or a uterus with no mobility, a pneumoperitoneum was performed with a Verres needle, and the pelvic cavity was assessed using a 5mm optics endoscope. In these cases, single-port surgery was not recommended; therefore, multiportal robotic access was chosen, and no intercurrent events were reported. Nine single-port cases were operated on by the same surgeon at Hospital Israelita Albert Einstein. Patient data analyzed included age, body mass index, previous surgeries, and clinical diagnosis. Surgical data included operative time, skin incision, report of intraoperative complications, need for conversion to laparotomy, need for transfer to intensive care unit, need for blood transfusion, inadvertent injury to other organs, length of hospital stay, and death.ResultsAll cases were completed with da Vinci Single-Site® system, with no intercurrent events. Four patients presented with adenomyosis as the surgical indication, two had uterine myoma, one endometrial cancer, one endometrial polyp, and one desquamative inflammatory vaginitis. The mean age of patients was 44 years (range, 40 to 54 years), and body mass index varied between 23.4 and 33.2kg/m2 (mean 26.4). No complications occurred in any of the cases, such as intestinal or bladder injury, bleeding, or the need for a second surgery. All nine procedures were completed with the robotic single-port access, and no patient required a blood transfusion.ConclusionAlthough this study merely presented an initial series of patients submitted to robotic single-port surgery, it demonstrated that the method is feasible and safe, suggesting the possible use of this technique in elective hysterectomy and other gynecological procedures in the future, as described in large reference centers of advanced surgery worldwide. Specifically, in gynecological practice, existing evidence on the use of robot-assisted, single-port surgery seems promising, and although it is not indicated in all cases, it should be considered as a surgical option. Nonetheless, further randomized and controlled clinical studies are necessary to establish the preeminence of robot-assisted, single-port surgery versus single-incision and conventional laparoscopy.

Rectovaginal Splenosis: An Unexpected Cause of Dyspareunia Approached by Laparoscopy

Study ObjectiveTo demonstrate the technique of laparoscopic approach in a rare case of rectovaginal splenosis with severe dyspareunia and dyschesia. DesignA step-by-step explanation of the patient's condition, diagnosis, surgical technique, and postoperative results (Canadian Task Force classification II-3). SettingSplenosis consists of ectopic functioning splenic tissue that can be located anywhere within the abdomen or pelvis. Fragments are often multiple and range in diameter from a few millimeters to a few centimeters. They are reddish-blue and are sessile or pedunculated. Their appearance can mimic that of neoplasms or endometriosis, which are the main differential diagnoses. Trauma and subsequent splenectomy is the cause in most cases. Splenosis is a benign condition usually found incidentally and is usually asymptomatic. The need for therapy is controversial, and treatment is suggested only in symptomatic cases, primarily those related to pelvic or abdominal lesions, as in our patient. The diagnosis of splenosis in a woman complaining of pelvic pain may present diagnostic difficulties. The splenic tissue has the macroscopic appearance of endometriosis, and its position in the pelvis also may suggest this diagnosis. Where excision of splenosis is considered necessary, the approach should be laparoscopic, unless this is considered too risky owing to the proximity of vital structures. InterventionA 40-year-old woman was referred to our department for severe dyspareunia and dyschezia. The gynecologic examination revealed a painfull nodularity on the posterior vaginal cul de sac. Further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging revealed several soft tissue nodules in the pouch of Douglas (POD), which were enhanced on contrast administration. She had undergone a splenectomy 15 years earlier after a car accident. A laparoscopic approach to a rectovaginal nodularity was performed. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her legs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the 0-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions. In the pelvis, hypervascular and bluish nodules were visible with extension from the POD into the deep rectovaginal space. The macroscopic appearance was atypical for endometriotic implants. The nodularities were carefully dissected and excised, and histological assessment revealed splenic tissue. At the time of this report, the patient had been asymptomatic for 6 months after surgery. ConclusionRectovaginal splenosis may mimic endometriosis. The laparoscopic approach to rectovaginal splenosis avoids an abdominal incision, with its associated pain and possible adhesion formation. It also provides a better view for dissection. In this patient, the splenosis was removed by laparoscopy, with no postoperative dyspareunia or dyschesia.

Trocar Injuries in 17,446 Laparoscopic Gastric Bypass-a Nationwide Survey from the Scandinavian Obesity Surgery Registry.

Although, the vast majority of bariatric procedures worldwide are performed laparoscopically, there is no consensus on the best technique to enter the first trocar, a potentially dangerous maneuver. Three principally different techniques exist: initial pneumoperitoneum by Verres needle, open Hasson technique, and direct placement of an optical trocar. In this nationwide survey, we have studied the presently used technique to place the first trocar and identified any intraabdominal injuries in 2012-2014. A questionnaire concerning techniques for placing the first trocar and identified intraabdominal injuries was sent to all 41 centers performing laparoscopic Roux en-Y gastric bypass (LRYGB) in Sweden. Total number of procedures were collected from the national quality registry, Scandinavian Obesity Surgery Registry (SOReg), also searched for reports on intraabdominal injuries. During the present study period, 17,446 LRYGBs were performed. Twelve intraabdominal injuries (0.07%) were found: bleedings from the omentum, small bowel mesentery and liver (n = 8), and gastric or small bowel perforation (n = 4). The injuries were evenly distributed between the Veress technique and direct placement of an optical trocar, while no injuries occurred with the Hasson technique. Concerning placement of the first trocar, initial pneumoperitoneum with Veress needle was most common (59%), followed by direct placement of an optical trocar (30%). This indicates a switch from 2009-2010 (Veress 45% and optical trocar 45%, p < 0.001). Twelve intraabdominal injuries (0.07%) were found in this nationwide survey. The most common technique for placing the first trocar had switched from directly placing an optical trocar to prior establishment of pneumoperitoneum.

Open Versus Closed Laparoscopy: Yet an Unresolved Controversy.

Safe placement of the Verres needle or the primary trocar for establishment of pneumoperitoneum is the most critical step in laparoscopic procedure as it is associated with bowel, bladder and life threatening vascular injuries and embolism. In the last few decades many techniques and guidelines have been introduced to eliminate complications in creation of pneumoperitoneum. Classical closed technique (Verres needle) and the open classic technique (Hasson) are the most commonly used techniques for creation of pneumoperitoneum. To compare the rate of occurrence and nature of complications in open and closed laparoscopy during establishment of pneumoperitoneum in different surgical and gynaecological procedures. This was a comparative study conducted at three hospitals in Dibrugarh district, Assam, India from January 2012 to December 2014. Total 3000 cases were included in the study with 1500 cases of open laparoscopy and 1500 cases of closed laparoscopy. Complications occurring in both the groups were compared by using Fisher's-exact test. In closed laparoscopy group minor complications occurred in 80 (5.33%) and major complications in 20 (1.33%) cases. In open laparoscopy group minor complications were observed in 60 (4%) and major complications in 2 (0.13%). The p-value of the difference between the two groups for minor complications was 0.0834 and for major complications was 0.0001(significant). Open laparoscopy was seen to be better than closed laparoscopy in terms of not only the rate of occurrence of complications but also the nature and severity of the complications. This study is clinically relevant as there is no consensus for a particular method of safe entry in to the peritoneal cavity warranting the need for more research. Open technique can be performed in all cases irrespective of previous operative scar, suspected intra peritoneal adhesions or obesity. Favourable outcome may be achieved in closed technique in cases of normal BMI, absence of postoperative scar in the abdomen, absence of abdominal and genital tuberculosis and pelvic inflammatory disease.

Verres needle desufflation as an effective treatment option for colonic perforation after colonoscopy.

This study aimed to assess the incidence of colonoscopic perforation and the efficacy of minimal invasive management by Verres needle desufflation. All colonoscopies performed between January 2007 and January 2012, at the Maastricht University Medical Centre, were reviewed. During the study period, 18,449 colonoscopies were performed. Fourteen colonoscopic perforations were diagnosed. Seven patients underwent immediate surgery, whereas the remaining 7 patients were initially managed conservatively: 5 of these patients also underwent Verres needle desufflation. One of the patients who received Verres needle desufflation underwent secondary surgery because of failure of nonsurgical treatment. Conservative management of colonoscopic perforation, including treatment with Verres needle desufflation, was associated with lower complication rates and shorter hospital stays compared with immediate surgical intervention. Verres needle desufflation in combination with nil per os and antibiotic treatment is a safe option for managing colon perforation after colonoscopy in selected patients lacking clinical signs of peritonitis or sepsis.

Addition

This article is primarily concerned with the question of optimal surgical approach (laparoscopy versus laparotomy) and well worth reading. I like to add three points which are important for the clinical management: Both the miscarriage rate and the preterm birth rate are not only influenced by the surgical approach, but also by the underlying condition. For instance, frequently a peritoneal inflammatory response (e.g. appendicitis) triggers uterine contractions (1). The literature review leaves it open whether the studies included in their analysis took the effect into account that the extent of inflammation had on the complication rate. The authors highlight the risk of injury to the uterus associated with the insertion of the Veres needle or trocar during laparoscopic procedures performed in pregnancy. By performing an “open” laparoscopy, this risk can be eliminated. Here, the approach (for example supra-umbilical) should be decided based on fundal height and, consequently, gestational age. According to the article, fetal and uterine status should be followed after the 16th week of pregnancy with “pre- and post-operative monitoring and documentation“. There is no recommendation for intraoperative monitoring (2) which is still a matter of controversy. From my personal experience, I know two cases of intrauterine fetal death associated with thrombectomy and the surgical removal of an abdominal tumor, respectively (both occurred between the 28th and 30th week of pregnancy). Chances are that both cases could have been avoided if intraoperative fetal monitoring had been carried out, with the team on standby to intervene immediately, if required. Intermittent or continuous cardiotocography- or ultrasound-based fetal monitoring can be performed with the transducer or ultrasound probe wrapped in sterile drapes (3). Prerequisites include adequate preoperative information of the patient and an infrastructure ensuring the availability of the necessary professional expertise and interdisciplinary cooperation (level I–II perinatal center).

Neumoperitoneo preoperatorio para el tratamiento de la hernia inguinal gigante: revisión de nuestra experiencia

ObjectiveTo assess the potential benefits of preoperative pneumoperitoneum in the management of giant inguinal hernias. Material and methodsProspective study using follow-up of two cases of giant hernias inguinoscrotal requiring preoperative pneumoperitoneum in our center from October 2013 to March 2014. ResultsDuring the last 5 months have been diagnosed two subsidiaries of giant hernias inguinoscrotal preoperative pneumoperitoneum in our center. These were 2 men with a mean age of 60.5 (55-66). None had clinically relevant and attended outpatients referred by other specialists. In one patient the hernia was bilateral and the other unilateral. As evidence of preoperative imaging in both cases computed tomography was performed.Patients admitted a week before surgery (range 6-8 days) to perform preoperative pneumoperitoneum by Verres needle placement with daily blow ambient air (between 240-1 000cc).It was performed as a repair technique in the 2 cases with preperitoneal hernioplasty posterior approach through a midline laparotomy. Highlight ileus as immediate complication (2-4 days). The mean postoperative hospital stay was 17.5 days (15-20 days). One month postoperative follow-up was performed with no evidence of complications, only underline the lack of reduction in size of the scrotum. ConclusionsProgressive preoperative pneumoperitoneum favors repairing giants hernias inguinoscrotal loss right at home. It is a safe and reproducible procedure with a low complication rate and high tolerability by the patient.