Verres Needle Research Articles

Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion

BackgroundWe have previously described the utility of ThoraQuik, a device designed to be fit for purpose for aspirations of pneumothorax and pleural effusions. We evaluated the safety, efficacy and operator...

Laparoscopic cholecystectomy at the Korle Bu Teaching Hospital, Accra, Ghana: An initial report

Laparoscopic cholecystectomy (LC) the preferred treatment for gallstones was not available in Ghana until 2005. To report experience from Ghana of laparoscopic cholecystectomy in the treatment of galestones. In a prospective study of patients with gallstones, information was obtained on demography, duration of various stages of the operation, analgesia and complication of patients with gallstones. All patients had general anaesthesia using endotracheal intubation, muscle relaxant and intermittent positive pressure ventilation. A standard four-trocar technique and maximum pneumoperitoneum pressure of 14 mmHg were maintained during surgery. There were 50 women and two men aged 17-72 years (mean 44.2 years). All had symptomatic gallstones treated by interval LC. The main indications were biliary colic 23(44%) and previous cholecystitis 15(29%). There were scars from previous abdominal surgery in 22 (42%), mainly pfannenstiel. The Verres needle was used to obtain pneumoperitoneum in 40 (77%). Only one patient (1.9%) had the operation converted to open cholecystectomy. Most patients, 47/51 (92%), were discharged in 24 hours. The mean durations of various stages were: anaesthesia (110 minutes), pneumo-peritoneum (67.5 minutes) and reverse trendelenburg (47.8 minutes). The mean operating time reduced from 81 to 68 minutes in the last 20 patients. Complications were sore throat 11(21.6%), infection of the umbilical wound 3(5.9%), right shoulder tip pain (3; 5.9%) and bile leak 1(2%). There was no peri-operative mortality. Elective laparoscopic cholecystectomy can be performed with good results in patients with symptomatic gallstones in Accra.

Establishing pneumoperitoneum: Verres or Hasson? The debate continues

The technique of establishing pneumoperitoneum for laparoscopic surgery remains contentious, with various different techniques available and each having its own advocates. The Verres needle approach has attracted much criticism and is seen to entail more risk, but is this view justified in the era of evidence-based medicine? Over a 6-year period, a prospective study was undertaken of 3126 patients who underwent laparoscopic surgery performed by two upper gastrointestinal surgeons. One surgeon preferred the Verres needle and the other an open technique. A database was created of all cases and complication rates of the different techniques ascertained. Peri-umbilical Verres needle was used in 1887 cases (60.4%) with two complications encountered, both of which were colonic injuries, with an incidence of 0.1%. Open port insertion was used in 1200 cases (38.4%) with one complication, a small bowel perforation, to give an incidence of 0.08%. The Verres needle was used in alternative positions in 22 cases (0.75%) and, when used in the left upper quadrant (19 cases), there was one complication, a left hepatic lobe puncture, with an incidence of 5.26%. Our overall incidence of intra-abdominal injury was 0.13%, all in patients who had undergone previous abdominal surgery, and in the subgroup of patients with previous surgery the rate was 0.78%. There was no mortality. Practice varies as to the method chosen to induce pneumoperitoneum, but our results show there is no significant difference between the technique chosen and incidence of complications, and this is supported in the literature.

New selective endoscopic sacral nerve root stimulation - an advance in the treatment of fecal incontinence

Fecal incontinence (FI) is a major part of illness and physical discomfort in the general population. Since the 1990s, sacral nerve stimulation has been well established in the treatment of neurogenic FI. The precise placement of the electrode is crucial for the success of the procedure. Eighty percent of the patients benefit from permanent treatment, but in 10-20% of the patients tested electrode placement proves impossible due to anatomical variations of the sacral foramina. In this study, we describe the technical requirements and a new method of electrode placement with reference to the anatomical (bone) landmarks in an animal model. With a small endoscope (Verres needle), we accessed the perirectal space to identify the nervous structures. A stimulated sphincter EMG was obtained for the experimental animals and muscle action potential (MAP/M-wave), latency time [ms], and the amplitude of the motor response [μV] were recorded. Electrodes were placed, the animals killed and dissected leaving the pelvic cavity untouched. The specimens were examined in a magnetic resonance scanner and in a multi-slice computed tomography scanner to detect the electrode material and possible surgical complications. After that the specimens were dissected. In all eight cases in the four animals tested, we were able to stimulate the sacral nerve as demonstrated by the EMG findings. No major surgical complications were observed for the procedure. Endoscopic sacral nerve root stimulation is a safe and effective method for delivering stimulation material in the pelvis of the sheep. It is a promising procedure to be tested in humans.

Management of residual pleural space and air leaks after major pulmonary resection

Postoperative air leaks associated with residual pleural space is a well known complication contributing to prolong hospitalization. Many techniques have been proposed for the treatment of this complication. Between 1999 and 2009, 39 patients with air leaks associated with residual pleural space (>3 cm at chest X-ray) persisting over three days after major lung resection were enrolled in this study. All patients were treated with combined pneumoperitoneum and autologus blood patch. Pneumoperitoneum is obtained by the injection of 30 ml/kg of air under the diaphragm, using a Verres needle through the periumbilical area. The blood patch is obtained by instillating 100 ml of autologus blood through the chest tubes. No patients experienced complications related to the procedure. Obliteration of pleural space was obtained in all the patients at a maximum of 96 h postoperatively. Air leaks stopped in all the cases at a maximum of 144 h from surgery. Chest tube was removed 24 h after the air leakage disappearance. Our 10-year experience supports the early, combined use of pneumoperitoneum and blood patch whenever pleural space and air leaks present after major pulmonary resection. This approach may be recommended because of its easiness, safety, effectiveness, and the low costs.

Commentary on: T. Sinnett, N. Karanjia (2009) Decompression of a pneumoperitoneum during a total extraperitoneal (TEP) inguinal hernia repair by incision of the umbilical sac under direct vision

Since total extraperitoneal (TEP) hernia repair was introduced in the early 1990s, there has been associated discussion regarding pneumoperitoneum. If the latter occurs, and this is not a rare event, the extraperitoneal space can become smaller. This can of course seriously interfere with the TEP procedure and in some cases can necessitate conversion to transabdominal preperitoneal (TAPP) or conventional hernia repair, especially in the early stages of the learning curve. As a solution to this problem many surgeons use a Verres needle for decompression of the peritoneal space. As Sinnett mentions in his letter to the editor, this method encompasses all the disadvantages and risks of blind peritoneal puncture. In addition, a Verres needle has a maximum flow rate of 2 l/min. So decompression takes time, or is impossible or unsatisfactory due to the much higher flow rate of any working trocar. Thus, according to in our experience, following a few unsuccessful attempts in 1994, we have never considered a Verres needle as the solution to the problems of pneumoperitoneum. Sinnett now mentions a new method of decompression by umbilical opening of the peritoneal sac. This of course seems to be safe, and probably gives rise to a better flow. However, due to surface tension, the smaller bubble (extraperitoneal space) will always blow up the bigger one (intraperitoneal space). Thus, in my mind, and in our experience, decompression of the intraperitoneal space does not provide a routine solution to the problem of peritoneal tears in TEP (in our hands close to 50% of procedures). We use a different procedure and, since we started with TEP, up to now we have never had a conversion due to pneumoperitoneum in more than 8,000 cases in two different clinics:

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.

Reply

We thank Richstone and Kavoussi for their sage comments. Clearly, the use of an adjunctive 2-mm needle-port is not always necessary, nor do we use it as such. However, in reconstructive cases, it offers a ready, morbidity-free solution to allow a more robust and confident surgical presence within the abdomen, enabling precise suturing. Requiring only a needle puncture for insertion, without any formal skin incision or skin suturing, the 2-mm Veres needle ports with an outer diameter akin to a 14-gauge intravenous needle, actually leave no visible scar. Indeed, in its upcoming white paper, the LESSCAR consortium panel ratified the discretionary use of the Veres needle port during LESS surgery. 1 Gill IS, Advincula AP, Aron M, et al. White paper. Consensus Statement of the Consortium for Laparo-Endoscopic Single-Site (LESS) Surgery. Surg Endosc. (in press). Google Scholar These are indeed exciting times. Laparoscopic surgery seems poised to advance to a new higher level. Laparoendoscopic Single-site Surgery: Initial Hundred PatientsUrologyVol. 74Issue 4PreviewTo report our initial experience with laparoendoscopic single-site (LESS) surgery in 100 patients in urology. Full-Text PDF Editorial CommentUrologyVol. 74Issue 4PreviewWe congratulate the authors for amassing the largest urologic experience with LESS procedures. They certainly demonstrate that this new laparoscopic technique is feasible and applicable to a variety of urologic pathologies. However, trying to interpret the results in this compilation of 13 different LESS surgeries is difficult—the tables provided can serve as initial benchmarks for perioperative outcomes. Focusing on the higher volume procedures reported, the LESS transvesical simple prostatectomy appears to be a challenging case requiring further refinement as complications occurred in 25% of cases (most being major complications). Full-Text PDF Editorial CommentUrologyVol. 74Issue 4PreviewWe applaud the authors for their work in assessing the applicability of laparoendoscopic single-site surgery (LESS). This approach is a more practical alternative to pure natural orifice transluminal endoscopic surgery (NOTES). Several previous studies have demonstrated the feasibility of LESS in urology, for both extirpative and reconstructive surgeries.1,2 The current series reviews to a considerable extent the safety and reproducibility of this technique. It should be pointed out, however, that in a significant proportion of these cases, the surgery described was not true “single-site surgery.” The authors note that all reconstructive cases (including partial nephrectomy, pyeloplasty, etc.) involved the use of an additional 2-mm trocar with accompanying instruments to complete these procedures. Full-Text PDF

Aktuelle Therapie der Cholezysto- und Choledocholithiasis – Umfrageergebnisse mit Analyse von 16 615 Eingriffen in Bayern

The aim of this study was the evaluation of the management of cholecysto- and choledocholithiasis and outcome of -laparoscopic as well as open cholecystectomy (CHE) and common bile duct (CBD) exploration in Bavaria, Germany. A written questionnaire -in-cluding 201 structured items was sent to all 180 hospitals and departments performing gen-eral or abdominal surgery in Bavaria. The response rate was 60 %. A total of 16 615 operations for gallstone disease including 16 051 cholecystectomies and 453 CBD explo-ra-tions with or without cholecystectomy were -reported. 88 % of all cholcystectomies started -laparoscopically, the conversion rate was 5.6 %. The Veres needle (69 %), 4 trocar techniques and electrosurgical hook knife were reported as standard procedures. A retrieval bag was used by 53 % of all surgeons. The overall complication rate for cholecystectomy was 5.46 % including 0.15 % -major bile duct injuries. Relaparoscopy was performed in 0.35 %, relaparotomy in 0.44 % and postoperative treatment by ERC in 1.45 %. The overall hospital mortality rate was 0.13 %. When choledocholithiasis was suspected, a two-stage management ("therapeutic splitting") with preoperative ERC was preferred (99 %). The conversion rate of simultaneous laparoscopic CHE+CBD exploration was 43 %. These results allow an estimation of the frequency and overall risks in surgical therapy for gallstones. At present, new techniques like combined laparoscopic and endoscopic proce-dures, microinstruments or N.O.T.E.S do not play a significant role in Germany.

Needle versus Tube Thoracostomy in a Swine Model of Traumatic Tension Hemopneumothorax

Objective. Traumatic tension hemopneumothorax is fatal if not treated rapidly. However, whether prehospital decompression is better achieved by chest tube or needle thoracostomy is unknown. We conducted this study to compare the immediate results and prolonged effectiveness of two methods of treatment for traumatic tension hemopneumothorax in a swine model. Methods. Ten percent of calculated total blood volume was instilled into the hemithorax of spontaneously ventilating swine (n = 5 per group, 40 ± 3 kg). A Veres needle and insufflator were used to induce tension hemopneumothorax. Animals were randomized to one of four groups: 1) needle thoracostomy with 14-gauge intravenous catheter; 2) needle thoracostomy with Cook catheter; 3) 32-F chest tube thoracostomy; or 4) no intervention (control). Serial chest x-rays were obtained to document mediastinal shift before and after treatment. Arterial blood gas values and physiologic data were recorded. Postoperatively, thoracoscopy was performed to detect possible pulmonary injury from the procedure and/or catheter kinking or clotting. Results. Positive intrapleural pressure was rapidly relieved in all treated animals. Four-hour survival was 100% in the 14-gauge needle and chest tube thoracostomy groups, 60% in the Cook catheter group, and 0% in the control animals (p < 0.05). There were no significant differences in survival or physiologic measurements among the treated animals (p > 0.05). Conclusions. In this animal model, needle thoracostomy using a 14-gauge or Cook catheter was as successful as chest tube thoracostomy for relieving tension hemopneumothorax.

Laparoscopic-assisted vaginal hysterectomy for endometrial cancer in high body mass index (BMI) patients: a report of six cases

In this case series, six women with high and very high body mass index (BMI; range, 30–65) underwent LAVH + bilateral salphingo-ophorectomy and removal of vaginal cuff under general anaesthesia for endometrial cancer. Initial Verres needle entry and insufflation was through the left upper quadrant at sub-coastal margin. With good surgical outcome, shorter hospitalisation and improved quality of life, we found that laparoscopic surgery was feasible in high and very high BMI patients with early stage endometrial cancer.

Laparoscopic entry—the experience of a range of gynaecological surgeons

Laparoscopic entry was prospectively assessed across a range of gynaecological surgeons working in a university teaching hospital to examine technique, difficulties experienced with entry and factors contributing to difficult laparoscopic entry. Details of 586 laparoscopies were obtained. Closed entry was used in 94.4% and open entry in 4.8%. Difficult laparoscopic entry occurred in 16.2% of cases. One or more entry tests were non-confirmatory in 21% of entries. Women weighing >100 kg had a higher rate of multiple Veres needle insertions than women weighing <100 kg (p = 0.006, odds ratio 3.06). Junior surgeons experienced more difficulty with laparoscopic entry than their more senior colleagues (p = 0.01). The laparoscopic entry complication rate observed intra-operatively was 0.68% (n = 4).

Transvaginal liver resection (NOTES) combined with minilaparoscopy

to report on the first liver resection performed on a human being by a transvaginal NOTES approach combined with minilaparoscopy. a sixty-one-year-old woman with a history of Wertheim s hysterectomy for endometrial carcinoma 10 years ago, and malignant melanoma correctly treated in 2006, had suspected segment-V liver metastasis near the gallbladder by CT-scan and MRI. The indication for a laparoscopic approach was made, and a combined transvaginal and minilaparoscopic resection was offered and accepted by the patient. The procedure was performed by a multidisciplinary team composed of surgeons and gastroenterologists. It involved creating a pneumoperitoneum by placing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second, 3-mm trocar was placed in the right upper quadrant. A lot of pelvic adhesions were found in the major pelvis, and it was necessary to place a third, 5-mm trocar in the left abdominal side. It was employed only for the adhesions, not for liver resection. Adhesions were removed to reveal the minor pelvis and the vaginal fornix. A colpotomy was performed with a 12-mm trocar placed inside the vagina, which allowed the insertion of the videogastroscope as far as the liver hilum. liver resection (segment-V partial resection) and cholecystectomy were performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The en bloc resection was removed transvaginally through the videogastroscope. There were no postoperative complications, and the patient was discharged after 48 hours. transvaginal liver resection is possible and safe when performed by a multidisciplinary team. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics. It will probably open the way for very important medical and technological innovations.

János Veres und die „Veres-Nadel“

Die operative Frauenheilkunde empfing zahlreiche Anregungen aus anderen operativen und nichtoperativen Fachgebieten. Für die gynäkologische Laparoskopie gehört bis heute die Veres-Nadel (nicht „Veress“-Nadel), die Erfindung des ungarischen Pulmonologen János Veres (1903 - 1979), zu den wichtigsten Instumenten. Veres publizierte seine Erfahrungen mit der neuen Nadel, die er für Pleurapunktionen entwickelte, zunächst in ungarisch und 1938 in der „Deutschen Medizinischen Wochenschrift“.

Laparoscopic management of a 20-cm ovarian cyst in a patient with a BMI of 70: a case report

A woman in her mid-40s with a body mass index (BMI) of 70 presented with lower abdominal pain of 24-h duration. The trans-abdominal scan revealed a large cystic ovarian mass. Laparoscopic salpingo-oophrectomy was performed by placing six ports in the upper abdomen; initial Verres needle entry and pneumoperitoneum were established through the left upper quadrant. A low CA-125 and the benign appearance of the ovary allowed the operation to continue laparoscopically with fewer perioperative complications. The histology of the specimen demonstrated a benign epithelial serous cystadenoma of the ovary with torsion.

Colecistectomía transvaginal (NOTES) combinada con minilaparoscopia

To report on the first transvaginal cholecystectomy performed on a human being in Spain. A 35-year-old female with a history of recurrent bouts of biliary pain resulting from gallstones. A surgical procedure was performed by a multidisciplinary team composed of surgeons, gastroenterologists, and gynecologists. It involved creating a pneumoperitoneum by placing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second 3-mm trocar was placed in the right upper quadrant. A colpotomy was performed, and a 12-mm trocar placed inside the vagina allowed the insertion of a videogastroscope as far as the hilum of the liver. Cholecystectomy was performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The gallbladder was removed transvaginally through the videogastroscope. There were no postoperative complications, and the patient was discharged within 24 hours. Transvaginal cholecystectomy is possible and safe when performed by a multidisciplinary team working together. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics than laparoscopic surgery. It will probably open the way for very important medical and technological innovations over the coming years.

Adrenalectomía bilateral simultánea laparoscópica para el tratamiento del Síndrome de Cushing

Cushing's syndrome is a rare disease. Most patients have a hypophyseal tumor and the treatment is neurosurgical. A small percentage of patients require bilateral adrenalectomy. This paper reports the cases of two patients undergoing bilateral simultaneous laparoscopic surgery with excellent results.Under general anesthesia, with the patient in the lumbotomy position right adrenalectomy was performed first. 15 mm Hg Pneumoperitoneum was started with the Verres needle in the ipsilateral upper quadrant; four trocars were placed, two 10 mm and two 5 mm. In both cases the adrenal vein was divided between metallic clips. Once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocar incisions. For the left side the position of the patient was changed, and the same procedure was performed using three trocars, two 10 mm and one 5 mm. No drainage was employed in either patient.The procedures were successfully performed without conversion. Surgical time was 150 minutes for the first patient and 210 for the second. Mean estimated blood loss was 125 ml. Mean hospital stay was 2.5 days. Both patients had a clinical reversion and they are managed with oral corticoid supplements.The results show that laparoscopic access to the adrenal gland is the approach of choice with very satisfactory outcomes for both patients and medical team.

Major complications arising from 1265 operative laparoscopic cases: A prospective review from a single center

Study objective To identify the volume and type of laparoscopic surgery being performed. To review the incidence, nature of associated complications, and reasons for conversion to laparotomy. Design A multicenter, prospective case load analysis and chart review, identifying operations performed by 6 advanced laparoscopic surgeons over a 12-month period (1/1/05 to 12/31/05). Setting Surgical cases were performed in 5 hospitals in Sydney, New South Wales. Patients One thousand two hundred sixty-five women underwent a variety of major and advanced operative procedures. Measurements and main results A total of 1265 major and advanced laparoscopic procedures were performed. Laparoscopic hysterectomy accounted for 364 cases (28.8%), pelvic floor repair and Burch colposuspension 280 cases (22.2%), excisional endometriosis surgery 354 cases (28%), adnexal surgery 177 cases (13.9%), adhesiolysis 75 cases (5.9%), and miscellaneous cases 15 (1.2%). Overall major complications in terms of bowel, urologic, or major vessel injuries accounted for 8 cases (0.6%). There were 4 injuries of the bowel, 2 injuries to the bladder, and 2 injuries to ureters. There were no major vessel injuries. There were no injuries associated with primary trocar or Veres needle insertion. The most common perioperative morbidity reported was the requirement for blood transfusion (11 cases [0.9%]), and the second most common was venous thromboembolism (4 patients [0.3%]). Six (0.5%) cases were converted to laparotomy, 2 as a result of a complication and 4 for technical reasons. Six of the 8 complications were managed laparoscopically, and a multidisciplinary input was sought only in 4 of the 8 complications. Conclusions Despite the advanced nature of laparoscopic procedures performed by our group, the complication rate and conversion to laparotomy remain low. There is an increasing feasibility to perform traditional open operations laparoscopically. An increasing number of these complications are now being managed laparoscopically by the gynecologist.

P12: Is the Verres needle an acceptable inflation tool to measure the abdominal pressure-volume relation

P12: Is the Verres needle an acceptable inflation tool to measure the abdominal pressure-volume relation

Laparoscopy After Previous Laparotomy

Following the abdominal surgery, extensive adhesions often occur and they can cause difficulties during laparoscopic operations. However, previous laparotomy is not considered to be a contraindication for laparoscopy. The aim of this study is to present that an insertion of Veres needle in the region of umbilicus is a safe method for creating a pneumoperitoneum for laparoscopic operations after previous laparotomy. In the last three years, we have performed 144 laparoscopic operations in patients that previously underwent one or two laparotomies. Pathology of digestive system, genital organs, Cesarean Section or abdominal war injuries were the most common causes of previous laparotomy. During those operations or during entering into abdominal cavity we have not experienced any complications, while in 7 patients we performed conversion to laparotomy following the diagnostic laparoscopy. In all patients an insertion of Veres needle and trocar insertion in the umbilical region was performed, namely a technique of closed laparoscopy. Not even in one patient adhesions in the region of umbilicus were found, and no abdominal organs were injured.