Preferred method for laparoscopic access

[DoctwoB]

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I've seen multiple attendings with difference practices including open dissection, veress needle, and optical separator ports. Most port-site related injuries I've seen have been related to abdominal wall bleeding, not injury to intra-abdominal contents. A quick lit search didn't find any direct comparison between methods. I'm curious about what the people on this board think is the best/safest method.

 

[anonperson]

After finishing residency and now starting fellowship, laparoscopic access is largely dependent on where you train. Every surgeon should be comfortable with at least two methods of entry in my opinion.

I didn't use the verses needle as much in residency but do more so now in fellowship. I never was a fan of blindly sticking a long metal needle in a patient blindly. It's largely a touch thing and has been used for years. I just get nervous of a major vascular injury.

I really liked using the optical trocar before insufflating the abdomen. I know it's meant for use after, but in a virgin belly, elevating the abdomen and driving down the trocar slowly really let me see the layers of the abdominal wall. During residency, I had no issues in the few hundred entries I was personally involved with. Plus the facial defect wasn't bad at all


Hasson technique is the old stand by. I just don't like the size of the incision and fascial defect but it works.

like mentioned above, there is a review comparing all the entry methods. Generally they are pretty safe.

 

[balaguru]

It really depends.

If the patient has an umbilical hernia then I amputate the stalk and place the trochar through the defect directly.

If using all 5mm ports, then veress at the umbilicus if no prior surgery otherwise optical trochar away from midline.

If using at least one >10mm port, then most of the time I use the direct technique with a curvilinear incision within the umbilicus unless the patient is super obese like BMI >50 and I think I will really have to dig my way to the fascia. In that case I use the same technique above with the veress or optical trochar and a carter Thomason for closure.

When I use the direct technique I place a figure of eight while the fascia is easily visible that I then pull up on it to maintain a seal with a standard >10mm port instead of using the Hassan trochar. At the end of the case I just pull up with a finger in the fascial defect to keep abd contents from getting caught and tie the stitch. I always test my closure with a pean and place extra suture if there is still a defect >5mm (i.e. if fascia was widened to remove GB).

Basically I try to be safe and efficient with time and equipment.

Frankly, I find the optical trochar away from midline to be more reassuring than the veress. If I make 2 attempts at obtaining pneumo with a veress and fail (usually preperitoneal) I always switch to the optical trochar.

 

[Winged Scapula]

@SLUser11 does a lot of advanced laparoscopy - wonder what his preferred method(s) is(are)?

I'd ask @Winged Scapula but she's too busy doing boob surgery. Probably doesn't even remember what a laparoscope is!

Hey now...I do remember and in fact, tried a technique a few months ago for releasing the upper pole of the pec in an infra mammary nipple sparing mastectomy via an transaxillary incision (http://link.springer.com/article/10.1007/s13193-011-0057-7).

I probably get a patient every few months asking me to do their surgery laparoscopically or without incisions. Maybe I'll try a NOTES approach next LOL!

 

[Winged Scapula]

Transvaginal mastectomy?

I was thinking transgastric but yours works for the older <ahem> less perky patients.

 

[filter07]

I like veress and carter thomason for closure. It's quick and easy, which is what I like. Hasson is cumbersome. I also like to go in with the visiport in the RUQ or LUQ. Just go and be done with it. Hasson has too many steps and you gotta wrap the suture around the port. Too many steps before getting on with the real reason you are there. Which is also why I didn't like CT surgery.

 

[anonperson]

Anyone use the Weck EFx closure device? I used it a bit at the end of residency and thought it was pretty slick although it didn't work perfectly all of the time. It seemed to work better on more obese patients compared to the thinner patients but overall I liked it better than the carter thomason.

http://www.teleflex.com/en/usa/productAreas/surgical/productGroups/closure/products/weckEfx/

 

[Smurfette]

I like veress and carter thomason for closure. It's quick and easy, which is what I like. Hasson is cumbersome. I also like to go in with the visiport in the RUQ or LUQ. Just go and be done with it. Hasson has too many steps and you gotta wrap the suture around the port. Too many steps before getting on with the real reason you are there. Which is also why I didn't like CT surgery.

I usually use a hasson (with a balloon port to hold it in place instead of sutures...less steps and also prevents air leak) if going in through umbilicus, visiport if going in elsewhere.

 

[dpmd]

I use a veress unless there is an umbilical hernia I am fixing at the same time then I do like balaguru. I don't use a carter thomason for closure though. I just elevate the fascia and close it. On the really fat folks I will grab the fascia edge with a kocher and if visualization is still a little poor I will slip the other end of my forceps in there like a tiny malleable. Haven't had a bowel injury yet (going in or going out), thankfully. There have been times where I end up under the omentum due to adhesions but am able to make a window to get out-had I been doing a hassan I might have thought that getting in wasn't safe and ended up with an open case in those situations. I might go for a LUQ entry if I am really worried about adhesions. I know some surgeons don't close any port sites smaller than a 15 but I can't bring myself to do that (except for my 5s and for my epigastric port as long as it didn't widen it too much-I take out my GB through the epigastric so I don't have to move the camera). I think the most important thing is to figure out something that works for you and just be consistent (with the ability to do some alternate methods when needed).

 

[JayDoc06]

Hasson for lap chole/appy/transverse colectomy, all at umbilicus; optiview for all other colectomies/proctectomies/robot

 

[dpmd]

Forgot to mention i go vertical for my infraumbilical port because my transverse incision always look a little stupid (because it is hard to stay perpendicular and what looks straight when you spread out the tissue looks crooked sometimes when you let it go) plus i can hide it up in the umbilicus nicely. I think it makes closing the fascia easier for me too.

 

[dpmd]

I like hiding the vertical incision in the umbilicus too, especially if I'm using Veress since I'll then just stick a 5 mm port in at the umbilicus. We do the 10 port at the epigastric region for lap choles and pull the gall bag out through that rather than the umbilicus, so there is really no need for a 10 port at the umbilicus. Anecdotally I feel like every postop wound infection I've seen for a lap chole is when the gb is pulled out through the umbilical port

I tried using a 5 at the umbilicus but our 5 scopes are terrible. I did one easy chole and it was still a little scary because the view was marginal. If it had been a bad one I could easily have cut something i shouldn't have. It is good enough for appys though (i like to have my camera at the llq and i staple through a 12 at the umbilicus).

 

[dpmd]

Our 5 scopes are good at our university hospital. The 5 scope at the VA is scary like you described.

I could probably bitch and have them get new ones but it didn't seem worth the effort when most of my patients aren't going to be harmed by a few extra mm of incision. These aren't bikini models I'm dealimg with.

 

[SLUser11]

I use all the above-described techniques selectively.

For virgin abdomens, I typically use a supra-umbilical veress needle. For reoperative bellies, I will use a supraumbilical hasson or a LUQ veress.

There have also been plenty of times when I've used the optiview, both before and after insufflation with a veress.

I firmly believe that a well-trained surgeon can use any of the above techniques, and can cater the technique to the situation. For that reason, I will often choose my approach based on the resident's experience with these options, as a way to improve his/her surgical repertoire.

Some side notes:
1. The literature shows most techniques to have equivalent minor and major complication rates.
2. A RUQ veress is not equivalent to LUQ. Make a mistake on the left side, and maybe you puncture stomach or SB. Make a mistake on the right, and there are lots of things that carry blood and bile, along with the unforgiving duodenum, that can come uninvited to the party.
3. I've completely abandoned infra-umbilical camera placement, and I've never missed it.

 

[thedrjojo]

3. I've completely abandoned infra-umbilical camera placement, and I've never missed it.

I like Infra-umbilical for lap choles, especially in smaller pts... As a crs, are you doing many lap choles nowadays? Most of your cases will be mainly focused in the lower abd (save for the hepatic and splenic flexures) so I'd think the Infra-umbilical would have less of a role.

Plus, gotta tailor the approach to the situation/patient 😉

 

[SLUser11]

I like Infra-umbilical for lap choles, especially in smaller pts... As a crs, are you doing many lap choles nowadays? Most of your cases will be mainly focused in the lower abd (save for the hepatic and splenic flexures) so I'd think the Infra-umbilical would have less of a role.

Plus, gotta tailor the approach to the situation/patient 😉

It's all preference, but I found myself regretting infraumbilical camera placement when:
1. The upper abdomen was farther away than anticipated, with worse visualization
2. Big patients and 5mm cameras where you have to crank on the camera to elevate the umbilicus, putting too much tension on it for my comfort.
3. Pelvic cases where it led to more sword fighting/less triangulation.

I almost never do a lap chole anymore....did 3 last year, and will likely do 0-1 this year, by choice of course....but I've done many many gallbags in my life, and always preferred supraumbilical.

 

[dpmd]

You guys that like the supraumbilical must get fewer of the short torso folks. I can't think of the last time i couldn't get close enough but can think of plenty of times my epigastric port would have been awfully close to a supraumbilical port. Will think of it the next long torso pt i have though. Funny how local differences pop up. I never knew it was possible for a guy to have an acute chole that wasn't ridiculously ugly until i rotated elsewhere.

 

[balaguru]

I generally have no help in the OR other than the scrub tech. For a routine lap chole I start on the pt's right side and place the umbilical trochar through a transverse infraumb incision followed by the upper abd trochars. I'm right handed and this feels most natural. If the pt is super obese then gravity pulls the umbilicus down and thins, relatively speaking, the wall of the upper abd. In those pt's I place the trochar through a vertical midline incision about 15cm below the xiphoid. For a lap appy I start the case and remain on the patient's left side and place the umb trochar through a transverse supraumbilical incision to gain space between instruments and because it's easier right handed. Colectomies to date have been for diverticulitis so port placement has been dictated by where I want to place my hand port. I haven't developed a preference yet.

 

[SLUser11]

I generally have no help in the OR other than the scrub tech. For a routine lap chole I start on the pt's right side and place the umbilical trochar through a transverse infraumb incision followed by the upper abd trochars. I'm right handed and this feels most natural. If the pt is super obese then gravity pulls the umbilicus down and thins, relatively speaking, the wall of the upper abd. In those pt's I place the trochar through a vertical midline incision about 15cm below the xiphoid. For a lap appy I start the case and remain on the patient's left side and place the umb trochar through a transverse supraumbilical incision to gain space between instruments and because it's easier right handed. Colectomies to date have been for diverticulitis so port placement has been dictated by where I want to place my hand port. I haven't developed a preference yet.

It's all preference. I tend to place ports with the left and right hand equally, based on the port location and my side of the bed. I like to grasp the umbilicus with a Kocher, then a penetrating towel clamp, as that's my favorite point of counter-tension during supraumbilical access. In training, I was frequently asked to put a Kocher through the incision itself to grasp the fascia while the veress went in, and I always preferred by one attending who just grabbed the belly-button, so that's how I do it.....not too interesting of a story, but just points out how our preferences are based on our previous attending's preferences, and how seeing it done several different ways allows us to develop perspective.

On a side note, I don't use hand ports a ton, but I still use them periodically....I used to use a periumbilical hand port for left colons/LARs during GS training, and I switched to a pfannenstiel during fellowship...much happier now.

 

[SLUser11]

oops double post

 

[vhawk]

how can you guys use that inane carter thompson thing? Just use the damn suture passer.

My preferred method is Veress needle, my backup method is Veress needle, third string is Veress needle somwhere else, and if that failed then I would use Hassan. Completely agree with whoever said that the Optical entry is completely misused, it is not for initial entry.

 

[rigid]

absolutely hate veress needle, and pretty much anything that is done blind

 

[vhawk]

Ultimately its all blind until yer in, its not like no one has ever injured bowel upon entry through a midline laparotomy incision

If surgeons were more patient we could probably make the Veress even smaller bore, then it wouldnt even matter how terrible you were at it, if the needle is small enough you can do whatever you want with it.

 

[Docgeorge]

Opti-view 5mm is my preferred method of entry. Bailout #1 is Hasson, bailout #2 is I do the case open.

 

[Kahreek]

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