Access to the Peritoneum and Avoiding Complications

Transcription

1 Access to the Peritoneum and Avoiding Complications Matthew Siedhoff, MD MSCR Associate Professor Minimally Invasive Gynecologic Surgery Cedars-Sinai UCLA David Geffen School of Medicine Disclosures Consultant! Applied Medical! Olympus! Medtronic! Caldera Medical! Teleflex 2

2 Objectives Understand relative merits of various methods of laparoscopic entry Review laparoscopic entry in challenging scenarios, including non-umbilical primary puncture such as Palmer s point Know relevant anatomy for avoiding vascular complications associated with entry and port placement 3 Entry techniques More than half of complications in laparoscopy occur during ENTRY Vascular injuries during entry are associated with a 15% mortality rate So what is the best method of entry?! Veress needle ( closed )! Hasson ( open )! Direct! Optical Krishnakumar+J+Gyn+Edosc+Surg+2009! 4

3 Entry techniques Ahmad+Cochrane+2015! 5 Entry techniques Systematic review: appropriate for rare outcomes 46 RCTs, 7389 subjects No advantage to any one technique in terms of preventing major vascular or visceral complications Open-entry outperformed closed with failed entry Direct-trocar entry outperformed Veress with failed entry and vascular injury Very small odds ratios, most not serious complications, statistical limitations, many studies excluded subjects w prior surgery, elevated BMI Ahmad+Cochrane+2015! 6

4 Veress entry Principles! Have the patient flat! Be mindful of distance to great vessels! Test the needle before entry! Connect insufflation tubing before entry! Listen / feel the cadence of the needle through layers! Confirmation: aspirate, drop test, pressure! Settings: 15-20mm Hg for entry! Insufflation: time, volume, pressure! Risk of injury increases with multiple attempts Teoh+JMIG Veress entry Multiple attempts increases risk of injury Number'of'a+empts' %'success' Complica4ons' One! 86%! Up!to!16%! Two! 10%! 16038%! Three! 3%! 44064%! >!Three! 1%! 85%+! Jiang+2012,+Krishnakumar+J+Gyn+Edosc+Surg+2009,+Richardson+Gyn+Endosc

5 Veress entry 9 Direct entry 10

6 Port placement Suprapubic Diamond! Operate two-handed from either side! Assistant! Cosmetic! Poor triangulation! Less ergonomic 11 Port placement 12

7 Port placement Suprapubic Diamond! Operate two-handed from either side! Assistant! Cosmetic! Poor triangulation! Less ergonomic 13 Port placement Ipsilateral! Improved triangulation! Better ergonomics! Less cosmetic 14

8 Port placement Ipsilateral! Improved triangulation! Better ergonomics! Less cosmetic 15 Port placement Ipsilateral! Improved triangulation! Better ergonomics! Less cosmetic 16

9 Port placement Ipsilateral! Improved triangulation! Better ergonomics! Less cosmetic 17 Port placement 18

10 Port placement Ipsilateral! Improved triangulation! Better ergonomics! Less cosmetic 19 Port placement 20

11 Port placement Palmer s!point! 21 Port placement 22

12 Port placement 23 Port placement 24

13 Port placement 25 Port placement 26

14 Port placement 27 Port placement 28

15 ! 49yo!g3p2012!with!years!of!heavy!menstrual!bleeding! and!anemia! CT:!10cm!ventral!vernia,!uterus!with!innumerable! fibroids,!24!x!32!x!27cm,!over!7000ml!in!volume! Surghx:!open!ventral!herniorrhaphy! Exam:!uterus!filling!the!cul0de0sac!and!extending!above! both!costal!margins! 260!lbs!(BMI!43!kg/m 2 )! Jehovah s!witness! 29 30

16 31 32

17 6095g! 33 Port placement 34

18 Port placement 35 Port placement 36

19 Port placement 37 Port placement 38

20 Port placement 39 Abdominal wall adhesions / prior surgery Ultrasound visceral slide-by test 40

21 Abdominal wall adhesions / prior surgery Visceral ultrasound slide-by test! Visceral slide < 1cm to predict adhesions " Sensitivity 86% " Specificity 91% " PPV 55% " NPV 98%! Works better awake in-office than under GETA Tu+AJOG Abdominal wall adhesions / prior surgery Visceral ultrasound slide-by test: Negative test ( good slide ) 42

22 Abdominal wall adhesions / prior surgery Visceral ultrasound slide-by test: Positive test ( bad slide ) 43 Abdominal wall adhesions / prior surgery 44

23 Abdominal wall adhesions / prior surgery 45 Obesity Ambardar+Surg+Endosc

24 Obesity 47 Obesity LUQ entry Umbilical insufflation, alternative first puncture trocar site Advanced fixation / balloon-tipped trocars Port placement Trendelenberg rests (flatten patient, let out CO 2 ) Defer request for steep Trendelenberg until deeper steps (e.g. colpotomy, cuff closure) Score posterior colpotomy first 48

25 Umbilical entry, alternate entry site 49 Advanced fixation trocars 50

26 Advanced fixation trocars 51 Port placement 52

27 Port placement 53 Port placement 54

28 Vessel injury Think!of!abdomen!like!a!dome!! Insert!perpendicular!to!the!fascia! Rahn+AJOG Vessel injury >!6cm!from!midline!at! or!above!the! Rahn+AJOG

29 Vessel injury Epigastric vessels! Superficial epigastric vessels " Variable in location " Visible by transillumination ~50%! Inferior epigastric vessels " Visible laparoscopically ~50% " Always between medical umbilical ligament and round ligament " Injury: o Foley catheter o Suture passer (Endoclose, Carter-Thomason) o Keith needle o Proximal and distal control Hurd+FerFl+Steril+2003,+Epstein+Clin+Anat Vessel injury 58

30 Vessel injury Near iliac crest, both nerves pierce deep or posterior surface of transversus abdominis muscle (TA). 59 Vessel injury 60

31 Vessel injury Aorta! R!common!iliac!artery! L!common!iliac!vein! Sandadai+JMIG Vessel injury 62

32 Vessel injury Major vessel laceration! If the patient is stable, evaluate injury, expanding hematoma! If present, put pressure and perform emergency (vertical) laparotomy while maintaining pressure on the area of bleeding! Call for vascular surgeon, blood and product! Don t be tempted to further evaluate yourself! In stand-alone center, may need to pack with lap sponges, quickly close abdomen w towel clips or running Nylon, transfer to hospital 63 Vessel injury 64

33 Vessel injury 65 Vessel injury 66

34 Vessel injury 67 References Ahmad G, Gent D, Henderson D, O'Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev Aug 31;8:CD Krishnakumar S, Tambe P. Entry complications in laparoscopic surgery. J Gynecol Endosc Surg Jan;1(1):4-11. Jiang X, Anderson C, Schnatz PF. The safety of direct trocar versus Veress needle for laparoscopic entry: a meta-analysis of randomized clinical trials. J Laparoendosc Adv Surg Tech A May;22(4): Richardson RF, Sutton CJG. Complications of first entry: a prospective laparoscopic audit. Gynaecol Endosc. 1999;8: Tu FF, Lamvu GM, Hartmann KE, Steege JF. Preoperative ultrasound to predict infraumbilical adhesions: a study of diagnostic accuracy. Am J Obstet Gynecol Jan;192(1):74-9. Nezhat CH, Dun EC, Katz A, Wieser FA. Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions. Obstet Gynecol May;123(5):

35 References Nezhat CH, Dun EC, Katz A, Wieser FA. Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions. Obstet Gynecol May;123(5): Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM, Steege JF. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol Nov-Dec;19(6): Chopin N, Malaret JM, Lafay-Pillet MC, Fotso A, Foulot H, Chapron C. Total laparoscopic hysterectomy for benign uterine pathologies: obesity does not increase the risk of complications. Hum Reprod Dec;24(12): Brezina PR, Beste TM, Nelson KH. Does route of hysterectomy affect outcome in obese and nonobese women? JSLS Jul-Sep;13(3): O'Hanlan KA, Lopez L, Dibble SL, Garnier AC, Huang GS, Leuchtenberger M. Total laparoscopic hysterectomy: body mass index and outcomes. Obstet Gynecol Dec;102(6): References Ambardar S, Cabot J, Cekic V, Baxter K, Arnell TD, Forde KA, Nihalani A, Whelan RL. Abdominal wall dimensions and umbilical position vary widely with BMI and should be taken into account when choosing port locations. Surg Endosc Sep;23(9): Rahn DD, Phelan JN, Roshanravan SM, White AB, Corton MM. Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery. Am J Obstet Gynecol Mar;202(3):234.e1-5. Epstein J, Arora A, Ellis H. Surface anatomy of the inferior epigastric artery in relation to laparoscopic injury. Clin Anat Jul;17(5): Hurd WW, Amesse LS, Gruber JS, Horowitz GM, Cha GM, Hurteau JA. Visualization of the epigastric vessels and bladder before laparoscopic trocar placement. Fertil Steril Jul; 80(1): Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol Nov- Dec;17(6):