Establishing Pneumoperitoneum

Veress Needle Technique

Pneumoperitoneum is most often established using a Veress needle. The needle is usually inserted at the site where the primary cannula for the laparoscope will be placed. Our preference is a vertical infra-umbilical incision because it overlies the location where the skin, fascia, and parietal peritoneum converge and fuse. If the patient has had prior abdominal surgery, we generally avoid the old incision scars and enter from a remote site in the upper abdomen.

After the skin is incised, the subcutaneous fatty tissue is bluntly dissected until the linea alba is visible. The linea alba is grasped using two Kocher clamps and pulled anteriorly. A "U-shaped" 2-0 or 0 fascial suture can be placed around the cannula insertion site at this time to facilitate later fascial closure, and the Veress needle is inserted perpendicular to the abdominal wall. Before using the Veress, the surgeon should check that the needle is patent and the spring-loaded safety mechanism is functioning properly. The needle should be held between the thumb and index finger not more than 3 cm from the tip to ensure it passes safely and steadily through the fascia (Figure 6.1). Steadying the heel of the needle-wielding hand on the abdominal wall will minimize the risk of uncontrolled insertion through the fascia. The needle should be advanced perpendicularly through the fascia for approximately 1 cm; then the needle should be directed toward the pelvis. As the needle's spring mechanism crosses the posterior rectus sheath and peritoneum, a definite give with a click is usually felt. Once inside the peritoneal cavity, the needle tip should feel free and move easily when the hub is moved laterally.

Once the needle is in place, its intraperitoneal location is verified with the following checks before gas insufflation:

1. A 10-mL syringe filled with normal saline is attached to the needle.

Three milliliters is injected and then aspirated. No resistance should

Gas Insufflation Laparoscopic Surgery
Figure 6.1. The Veress needle is held between the surgeon's thumb and index finger midway up the shaft. The risk of plunging deeply can be minimized by placing the base of hand on the body wall (asterisk).

be felt during injection. The aspirate is examined for return of blood, urine, or bowel contents. 2. The "hanging drop" test is performed, which confirms that the needle has entered a cavity. The test is done by relaxing all retraction on the abdominal wall, placing a drop of saline on the open hub of the Veress needle, then lifting up the Kocher clamps placed on the abdominal fascia. When the clamps are lifted, the saline will quickly drop into the peritoneal cavity if it has been entered.

Although these tests merely indicate whether a cavity has been entered, and may not distinguish between the peritoneal cavity and the preperitoneal space or a hollow viscera, we believe these tests should always be performed before gas insufflation.

After the syringe test and the drop test, the insufflation line is connected to the needle and CO2 insufflation is started. The intraabdominal pressure is monitored during early gas insufflation (Table 6.1). The pressure should be less than 5 mm Hg at the beginning of CO2 insufflation. If the pressure is greater than 5 mm Hg, the needle can be either in the abdominal wall, preperitoneal space, adjacent to or within an intraabdominal viscus, or buried in the omentum. Elevating the abdominal wall and repositioning the needle (usually by simple axial rotation) will almost always result in proper pressure readings. If the pressure remains elevated or increases rapidly over 10 seconds, the needle tip is likely misplaced, and it should be removed immediately and inserted again, or the surgeon should consider an open technique.

Table 6.1. CO2 monitor reading - various scenarios on Veress needle insertion

Pressure

Flow

Abdominal distension

Possible etiology

Starts low

1

Low at first

Distends gradually

Normal

Rises gradually

Starts low Stays low

Low at first Stays high

2) Needle in hollow organs or intravascular

Starts low

Stays low

Low at first Then none

Not much or no distension

Empty CO2 cylinder

Starts high

1 ' Stays high

Low or none

No distension

1) Occlusion in system

2) Needle in abdominal wall, adhesions, or intramural (organ)

Open-Hasson Technique

Although some surgeons use the "open-Hasson" technique routinely in all patients, it is still controversial whether this technique minimizes risks of injury to the abdominal viscera at the initial abdominal access.1 However, surgeons should always readily move to the open technique when any difficulties arise using the Veress needle technique. Currently, we use this technique selectively when dense intraabdominal adhesions are suspected: e.g., cases with history of prior major abdominal surgery.

In this technique, the peritoneal cavity is opened and a blunt-tipped open "Hasson" cannula is introduced under direct vision through a mini-laparotomy. The standard open cannula consists of three pieces: a cone-shaped sleeve, a sheath with a trumpet or flap valve, and a blunt-tipped obturator. The sleeve can be moved up and down the sheath until it is properly positioned. There are two suture struts on the sleeve or the sheath to affix the cannula to the fascial and peritoneal incisions.

A 2-cm skin incision is made at the selected entry site. A longer incision will result in the major leakage of CO2 gas during the insufflation. The subcutaneous tissue is bluntly dissected and the underlying fascia is identified and incised. This incision should be just long enough to admit the surgeon's index finger. The abdominal entry is confirmed visually and by digital palpation, to ensure the absence of intraabdominal adhesions in the vicinity of the incision. The cannula is then inserted under direct vision between two hemostats that grasp the peritoneum. Two sets of 0 or 2-0 sutures are placed on either side of the fascial incision and wrapped around the struts to firmly seat the cannula in the peritoneal cavity (Figure 6.2). Some surgeons place these fascial sutures first, use these to elevate the fascia, and then make the fascial incision. Care should be taken not to deeply open the fascia, because underlying peritoneum and viscera can be damaged in thin patients. The CO2 line is connected to the sidearm port and pneumoperitoneum is established under continuous monitoring of the intraabdominal pressure.

Use of Optical Access Trocar

The third alternative for the establishment of pneumoperitoneum is the use of so-called optical access trocars. The trocar used in this technique (e.g., Bladeless Trocar; Ethicon Endo-Surgery, Cincinnati, OH) has a clear, tapered (bladeless) optical obturator, which provides visibility of individual tissue layers during insertion when used with an endoscope. A 0° or 30° endoscope connected to the light source and monitor is inserted into the opening at the proximal end of the obturator until it reaches the distal tip of the obturator. The obturator is then introduced through a skin incision and advanced by applying continuous but controlled pressure with a rotating motion. The penetration of the obturator tip is endoscopically monitored and the individual tissue planes can be seen as the obturator tip advances (Figure 6.3). The trocar advances by dilating the tissue planes, not by cutting. After laparoscopic verification of the intraperitoneal placement, CO2 insufflation is started directly through the cannula. This technique is best suited for obese patients with a thick abdominal wall, where a standard "open" technique via mini-laparotomy is occasionally technically difficult.

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