Laparoscopic entry techniques

Abstract

Analysis 9.6. Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 6 Radially expanding (STEP) trocars vs standard (non-expanding) trocars (secondary port entry).. Analysis 9.7. Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 7 X-cone vs Veress needle entry.

Laparoscopic surgical access in morbidly obese women undergoing endometrial cancer surgery: Repurposing the left upper quadrant approach

“…Ninety eight percent of women in this series experienced a successful LUQ laparoscopic trocar placement with a low complication rate of 0.3 % in the hands of high-volume gynecologic oncologists with expertise in MIS. Morbidly obese women, particularly those with a large panniculus, are at greater risk for perioperative complications related to their central and visceral adiposity [21]. Given the well-established decrease in perioperative complication rates and shorter recovery periods when compared to laparotomy, MIS is of particular benefit for these women.…”

“…In obese patients, the distance from the skin to peritoneum is increased, which may further complicate initial trocar placement [20,22]. A Cochrane review highlighted the association of the Veress needle insertion with a higher rate of pre-peritoneal insufflation and omental injury in this patient population [21]. The purported visualization benefits of the Hasson technique are hampered by the increased adiposity inherent to the obese patient and can lead to difficulty maintaining pneumoperitoneum [29].…”

“…The umbilicus is displaced caudally by the panniculus as central adiposity increases, rendering it more difficult to correlate intraperitoneal anatomy with the umbilical location [20]. Furthermore, abdominal obesity increases the depth of entry at the umbilicus and increases the risk of pre-peritoneal entry and insufflation with subsequent conversion to laparotomy [21]. Although the overall risk of injury during laparoscopic entry is low in the hands of experienced surgeons, approximately 50 % of all laparoscopic injuries occur with initial abdominal trocar placement [21,22].…”

“…Furthermore, abdominal obesity increases the depth of entry at the umbilicus and increases the risk of pre-peritoneal entry and insufflation with subsequent conversion to laparotomy [21]. Although the overall risk of injury during laparoscopic entry is low in the hands of experienced surgeons, approximately 50 % of all laparoscopic injuries occur with initial abdominal trocar placement [21,22]. This possibility of injury may be increased in morbidly obese women [23].…”

“…The left upper quadrant (LUQ) laparoscopic approach is an alternative strategy to obtain intra-peritoneal access, which was originally described by Palmer in 1974 [24]. This technique is often used when entry through the umbilicus is challenging or contraindicated, such as suspected periumbilical adhesions, myomatous uteri (organ perforation), large ovarian cysts (mass rupture), or the final two trimesters of pregnancy (bleeding complications) [21]. Given anatomic challenges with laparoscopic entry in obese women, the LUQ approach may have utility for these women.…”