Abdominal anatomy in the context of port placement and trocars

Abstract

Review 241Introduction Extra-abdominal relevant anatomy Anatomical basis: The anterior abdominal wall has four muscles that are penetrated at all entries: rectus abdominis, external obliquus abdominis, internal obliquus abdominis, and transversus abdominis. Although the penetrating areas are variable in laparoscopy, the usual trocar placement uses similar inserting areas. Therefore, it is obligatory for any surgeon to be experienced in the anatomy of the abdominal wall and its consecutive relevant anatomical structures. There are no significant vascular structures that need to be respected upon insertion of the subumbilical trocar. Solely, strict attention has to be given to holding to the median line to avoid any accidental damage to paramedian structures. There are two arteries in the superficial abdominal wall that should be visualized. Damage to these arteries should be avoided because even superficial incisions can lead to severe bleeding that requires the conversion from laparoscopy to laparotomy. Both vessels can be visualized by diaphanoscopy (Figures 1-4). Trocar placement is performed, dependent on the corresponding internal site, at a 90° angle to the abdominal wall once the aiming point has been located. The superficial epigastric artery arises from the femoral artery approximately 1 cm below the inguinal ligament through the fascia cribrosa, turns upward in front of the inguinal ligament, and then ascends while spreading out between the two layers of the superficial fascia of the abdominal wall, nearly as far as the umbilicus. The circumflex iliac superficial artery originates from the femoral artery close to the superficial epigastric artery. After perforating the fascia lata, it runs parallel to the inguinal ligament and laterally to the iliac crist while spreading into smaller branches (1). Places for trocar insertionThe laparoscope and optic trocar should be inserted, whenever possible, in the subumbilical region using a semilunar or straight incision (Figure 1). Only if trocar placement is not possible, e.g., due to severe adhesions or large intra-abdominal tumors, are alternative entry sites negotiated, e.g., above the umbilicus or Palmer's point (Figure 5), as a precursor entry site.The placement for the working trocars depends on the operation. If the operative focus is located in the pelvis and no large tumor is expected to be touching the umbilical region, the two working trocars can be inserted in the lower abdominal wall in a vessel-free area, as confirmed by diaphanoscopy. Any auxiliary trocar can be placed in the midline suprasymphysically or left of the midline. A maximum distance between the optic trocar and the working trocars should be Although the anatomy of the human being has not changed, technical developments in operating materials and methods demand a simultaneous development in operative management. Developments in electronic and optical technologies permit many gynecological operations to be performed laparoscopically. One fundamental distinction between any other operating...

<p>Interfascial Plane Blocks and Laparoscopic Abdominal Surgery: A Narrative Review</p>

“…The open-entry, or Hasson, technique describes placement of a blunt trocar through a subumbilical incision to insufflate the intraperitoneal cavity. 87 In contrast, the closed-entry technique describes insertion of a Veress needle in the umbilical region to insufflate the intraperitoneal cavity. 87 Abdominal wall nerve blocks that provide analgesia to the T10 thoracoabdominal nerve should provide sufficient cutaneous analgesia for the Hasson and closed-entry techniques.…”

Transumblical versus Infraumblical pneumoperitoneum: A comparative study.

“…There is no fat and preperitoneal layer, so the umbilicus is thin even in obese patients and this allow an easy access to the abdominal cavity and this site is comparatively bloodless during port placement. 7 The umbilicus was cleaned with spirit soaked cotton gauze and if there was any debris deep inside, was taken out manually. The base of the umbilicus was everted and held with Allis forceps.…”

OneShot-M: A New Device for Close Laparoscopy Pneumoperitoneum

“…In addition, open access leads to irritating air leakage due to large incision, especially in obese patients, and is associated with a higher rate of wound infection. 30 Several randomized studies and a Cochrane analysis did not report significant evidence of safety for both techniques. [31][32][33] The Swiss Association for Laparoscopy and Toracoscopic Surgery (SALTS) collected prospective data on 90.3% of low-risk patients submitted to various laparoscopic procedures between 1995 and 1997 (14 243 patients, male/female ratio 0.7).…”

“…Dunne et al 28 Two unspecified vascular lesions Laparotomy, without further complications Pasic 29 Inferior cava vein Laparotomy and venography Alkatout et al 30 Gaseous embolism Cardiopulmonary resuscitation with clinical sequelae Prolonged hospital stay Royal College of Obstetricians and Gynaecologists 31…”