Gaining Access
Access to the peritoneal cavity
and creation of pneumoperitoneum is the initial step in laparoscopy.There are
different methods of primary access in laparoscopy. The popular ones being the
Veress needle technique and Hasson’s technique. Veress needle technique still
being used by many surgeons and gynaecologists is regarded by them as the Gold
standard. As the veress needle and the first trocar afterward are introduced
blindly, this method is called closed method contrary to the open technique
named as Hasson’s technique where peritoneum is approached by open dissection
of tissues.
The veress needle technique
Umblicus is
the site chosen as the primary access site. The reasons are it is in the
midline and it is naturally a weak area due to absence of all the layers.
The anterior
abdominal wall should be lifted or stabilized before the insertion of the
needle or stabilized before the Veress needle is inserted. Only three
attempts for successful pneumoperitoneum establishment are acceptable, fourth
attempt should be made in an alternative site. One of these sites is the
Palmer’s point localized about 3 cm below the left costal margin in the
midclavicular line. This is the site especially recommended in extremely obese
and thin patients,
The Veres needle should be inserted in angle from 45° in
non-obese to 90° in obese patients. There are various methods like hanging drop
of saline test, the “hiss” sound test, aspiration and syringe test, that prove
correct localization of the needle.
Then pneumoperitoneum is created using CO2 insufflator.
The last is the introduction of the first trocar, it has a
potential in damaging major vessels or organs.So it is essential to elevate the
abdominal wall.It should be introduced carefully with the rotatory motion. Just
after the insertion of the first trocar, the insufflation cord should be
connected to maintain the pneumoperitoneum.
Secondary Access
After taking the primary access secondary access of the
other trocars should take place. The site and no of placement differ according
to the procedure. Telescope should be
in the middle of instruments. Manipulation
angle of instruments usually 60 degree but can differ according to procedure.
The picture shows the placement of camera, target and instrument ports.
When inserting the
ports, abdominal wall has to be pulled up and trocar inserted in a twisting
manner. This has to be stopped when the trocar enters the cavity.
