I palpate the edge of the ribs at the midclavicular line at the costal margin and carefully slide a #11 blade right along the lowermost rib to create an incision only large enough to accommodate a 2-mm scope. This incision will require no stitch—just a Steri-strip—to close.
I insert a Veress needle perpendicularly, feeding it through the abdominal wall with my finger and thumb. It's a very tactile move. You should feel the clicks.
Precisely because entry at this site feels different from entry at the umbilicus, I favor doing the entry this way every time; you learn the feel of doing it right.
I then inject saline through the needle and aspirate. If solution has entered the abdominal cavity, I don't get it back. If I had entered the bowel, the return would be greenish brown or blood-tinged, and further evaluation would be required.
I then insufflate the abdomen with enough carbon dioxide to increase the intraabdominal pressure to 25 mm Hg. The volume required will vary from patient to patient. A postpartum patient may require 12 L of carbon dioxide to reach that degree of pressure; a marathon runner with a tight abdomen may get there with 4 L.
This step accomplishes the third goal: optimizing conditions to avoid retroperitoneal structures, the major vessels.
When intraabdominal pressure is at only 12 mm Hg, the abdominal wall is very close to bowel, leaving no room for error. Increased pressure leaves a bigger space between the anterior abdominal wall and the intraabdominal and retroperitoneal structures, providing a comfortable margin of safety. This is especially critical in very thin patients, whose major vessels may lie very close to the anterior abdominal wall.
Through the same small, upper-left quadrant incision, I insert a 2-mm trocar and cannula for a small laparoscope to inspect the abdomen, identify the inferior epigastric vessel, assess the location of any adhesions, and ensure that no structures have been damaged or are in the path of any intended trocar site.
For some cases, such as tubal ligation, it is possible to use this as the primary port.
More commonly, it is at this point that I determine whether I can place my primary port in the umbilicus, and I do so under direct visualization before proceeding with my surgical procedure.
It is widely believed that laparoscopic surgery injuries are underreported. Nonetheless, patterns can be determined.
A prospective, multicenter study of complications of laparoscopy conducted in the Netherlands identified 29 bowel injuries and 27 major vessel injuries in 25,764 procedures for an identical rate of 0.11%.
More importantly, with regard to entry technique, Richard Soderstrom, M.D., found in a medicolegal review that the primary port was responsible for half of all major vascular injuries during 47 endoscopic cases (J. Am. Assoc. Gynecol. Laparosc. 1997;4:395–8).
A review of malpractice cases after 296 laparoscopic cholecystectomies performed using a primary umbilical entry site found that 86% of major vascular injuries were caused by the primary port and 75% of gastrointestinal injuries were caused by a trocar (J. Gastrointest. Surg. 1997;1:138–45).
Bowel injuries can occur with any laparoscopic technique and with laparotomy as well; some studies suggest a greater risk of injury with the latter approach. Because no method has been devised to completely avoid these injuries, the key is to recognize them, either at the time of surgery, or when the patient fails to improve as expected during the postsurgical course.
We have the potential to entirely avoid major vascular injuries by use of upper left quadrant entry before placement of a central port at the umbilicus and placement of accessory trocars.
By combining appropriate entry tools, a left upper quadrant entry site, and adequate insufflation of the abdomen, risks can be reduced at every step of laparoscopic surgery.
Dr. Duncan Turner, who is performing this procedure, prefers an entry site in the left upper quadrant to avoid major structures and potential adhesions from previous surgery.
Direct visualization and adequate insufflation leave plenty of room for error when the trocar enters the intraabdominal space as shown in this image. Photos courtesy Dr. Duncan Turner
'Do No Harm'
Physician, do no harm is a credo all gynecologic surgeons must live by. Nowhere do these words ring more true than during laparoscopic surgery. With the slightest lapse in technique, the simplest of laparoscopic procedures can quickly become a nightmare both for the patient as well as the surgeon. And when is the greatest risk of injury during a laparoscopic procedure? At entry.