access to the peritoneum and avoiding complications...ahmad+cochrane+2015! 6 entry techniques •...

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

2

Disclosures

• Consultant ! Applied Medical

! Olympus

! Medtronic

! Caldera Medical

! Teleflex

3

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

4

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!

5

Entry techniques

Ahmad+Cochrane+2015!

6

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!

7

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+2005+

8

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+1999+

Veress entry

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Direct entry

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11

Port placement

• Suprapubic “Diamond” ! Operate two-handed from either side

! Assistant

! Cosmetic

! Poor triangulation

! Less ergonomic

ASIS! ASIS!

Port placement

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13

Port placement

• Suprapubic “Diamond” ! Operate two-handed from either side

! Assistant

! Cosmetic

! Poor triangulation

! Less ergonomic

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Port placement

•  Ipsilateral !  Improved triangulation

! Better ergonomics

! Less cosmetic

ASIS! ASIS!

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Port placement



! Less cosmetic

ASIS! ASIS!

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Port placement



! Less cosmetic

ASIS! ASIS!

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Port placement



! Less cosmetic

ASIS! ASIS!

Port placement

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Port placement



! Less cosmetic

Port placement

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Port placement

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ASIS! ASIS!

Palmer’s!point!

Port placement

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Port placement

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Port placement

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Port placement

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ASIS! ASIS!

Port placement

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ASIS! ASIS!

Port placement

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Port placement

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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/m2)!Jehovah’s!witness!

!

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31

32

33

6095g!

Port placement

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ASIS! ASIS!

Port placement

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ASIS! ASIS!

Port placement

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Port placement

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ASIS! ASIS!

Port placement

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Port placement

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Abdominal wall adhesions / prior surgery

• Ultrasound visceral “slide-by” test

the overlying anterior abdominal wall. Kodama et alshowed that 5 patients without a history of previousabdominal surgery had ultrasound-visualized movementof the underlying viscera (visceral slide) of at least 2.5cm during exaggerated respiration; none had adhesionsat time of abdominal surgery. They also tested 13patients with surgical or other risk factors for adhesions;of the 7 with visceral slides less than 1 cm, all hadadhesions beneath the scar.4 Caprini et al studied 30patients with previous abdominal surgery, successfullyidentifying all 4 patients with infraumbilical adhesionswhile excluding the 26 normal patients, using the samecutoff.5 In contrast, Uberoi et al, using visceral slidethresholds of 1.2 to 1.5 cm in all 4 abdominal quadrants,studied 48 patients undergoing abdominal surgery. Theyreported a sensitivity of 21% and specificity of 94%, andexpressed concern for the large number of false positivesencountered.6 The latter 2 studies observed visceral slideduring spontaneous respirations, rather than exagger-ated respiration.

Although other techniques exist for minimizing bowelinjury at initial needle/port placement in high-riskwomen, such as choosing the left upper abdominalquadrant for primary entry, or performing a smalllaparotomy for umbilical port placement, none com-pletely eliminates the risk.7 In addition, a recent meta-analysis comparing safety of small umbilical laparotomyversus blind needle placement found a lack of evidenceto favor one method over the other.8 The present studyquantifies the test characteristics for preoperative ultra-sound measurement of visceral slide as a predictor ofinfraumbilical adhesions.

Material and methods

We measured visceral slide preoperatively in a series of60 women with risk factors for intra-abdominal adhe-sions. Participants were approached between January 1,2003 and June 13, 2003 for consent to participate in thestudy while in the UNC Hospitals Women’s and Child-ren’s Hospital preoperative waiting area on the morningof their procedure. Ninety-five percent of womenapproached gave consent, as shown by the participantflow diagram in Figure 1. Authorization for the studywas obtained from the UNC Medical School Institu-tional Review Board. This nonconsecutive, conveniencesample met the following inclusion criteria: age 18 yearsor older, history of abdominal surgery (includinghysterectomy, cesarean delivery, tubo-ovarian surgery,tumor debulking, intestinal resection, gastric bypass,appendectomy, cholecystectomy, or umbilical hernior-rhaphy), or history of pelvic inflammatory disease. Allparticipants were scheduled for either laparoscopy orvertical laparotomy for a gynecologic condition (43%hysterectomy, 28% ovarian surgery, 10% adhesiolysis,8% diagnostic laparoscopy, and 10% other.) Womenundergoing vertical laparotomy were included for 2reasons: first, because visualization of scar tissue un-derneath the umbilicus could be evaluated equally wellwith these incisions compared with laparoscopy; second,they enhanced the spectrum of disease within the studypopulation.

This was a cross-sectional study design. A total of 60participants were chosen for this study based on samplesize calculations to achieve narrow confidence intervals

Figure 2 Ultrasound visualization of movement of abdominal viscera (visceral slide) during inspiration in an adhesion-freevolunteer. The ultrasound transducer is positioned longitudinally over the umbilicus, and the woman is asked to take deep breaths inand out. Time A is at expiration, time B is after inspiration. The bowel (discernable by the presence of a round echogenic focus withperistaltic activity inside) moves inferiorly with inspiration away from the diaphragm (the lefthand side of each ultrasound) towardthe pelvis (the right hand side of each ultrasound). Distance traversed by the bowel (dotted circles) longitudinally is measured asvisceral slide (here, 2.02 cm).

76 Tu et al

41


• 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+2005+

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• Visceral ultrasound “slide-by” test: Negative test (“good slide”)

43


• Visceral ultrasound “slide-by” test: Positive test (“bad slide”)

44


ASIS! ASIS!

45


ASIS! ASIS!

Obesity

46

of low-riders in each BMI group was calculated and

compared using the chi-square test and the Fisher exact test(for expected frequency of less than 5).

Values of p\ 0.05 were considered statistically signif-

icant. All statistical analyses were performed by usingSPSS version 15.0 (SPSS, Inc., Chicago, IL).

Results

Of the 259 patients studied, 6 were classified as under-

weight, 96 as normal, 75 as overweight, and 82 as obese.

There were a total of 119 females and 140 males (Table 1).The results for each BMI category are reported below.

Underweight patients

For the six patients classified as underweight, the median

BMI for the group was 17.7 kg/m2 (IQR 16.5–18.3 kg/m2);

the median torso length was 27.7 cm (IQR 26.6–28.9 cm);and the median abdominal girth was 27.5 cm (IQR 24.8–

28.0 cm). The median umbilical position in this group of

patients was 0.87 cm below the halfway point of the torso(IQR -1.38 to 0.19 cm) (Fig. 1, Fig. 2). The umbilicus

was equidistant between the xiphoid process and pubis in

five out of six patients (83.3%) and low-riding in one out ofsix patients (16.7%) (Table 3). This group was too small to

permit a comparison of the results in relation to gender

(four females and two males).

Normal patients

For the 96 patients classified as normal, the median BMI forthe group was 22.2 kg/m2 (IQR 20.3–23.5 kg/m2); the

median torso length was 31.5 cm (IQR 29.5–33.5 cm); and

the median abdominal girth was 29.5 cm (IQR 27.0–32.0 cm). The median umbilical position in this group of

patients was 0.88 cm below the halfway point of the torso

(IQR -2.00 to 0.50 cm) (Fig. 2). The umbilicus wasequidistant between the xiphoid process and pubis in 70/96

patients (72.9%), low-riding in 24/96 patients (25%), and

high-riding in 2/96 patients (2.1%) (Table 3). Regarding themale and female subgroup data, the BMI for females was

significantly greater than the BMI for males (p = 0.048),

but there were no significant differences in torso length,abdominal girth, or umbilical position (Table 4).

Overweight patients

For the 75 patients classified as overweight, the median

BMI for the group was 26.6 kg/m2 (IQR 25.8–28.3 kg/m2);

the median torso length was 33.0 cm (IQR 31.2–35.0 cm);and the median abdominal girth was 32.0 cm (IQR 30.0–

38.0 cm). The median umbilical position in this group of


(IQR -2.25 to -0.50 cm) (Fig. 3). The umbilicus was

equidistant between the xiphoid process and pubis in 53/75patients (70.7%) and low-riding in 22/75 patients (29.3%)

(Table 3). Regarding the male and female subgroup data,

there were no significant differences in BMI, torso length,abdominal girth, or umbilical position (Table 4).

Obese patients

For the 82 patients classified as obese, the median BMI for

the group was 36.9 kg/m2 (IQR 32.2–42.8 kg/m2); the

Fig. 1 Correlation between BMI (kg/m2) and abdominal dimensions(cm), showing the correlation between BMI and torso length (A),abdominal girth (B), and umbilical position (C). A positive correla-tion was found between BMI and both torso length and abdominalgirth. A negative correlation was found between BMI and umbilicalposition

Surg Endosc (2009) 23:1995–2000 1997

123median torso length was 38.0 cm (IQR 32.6–42.2 cm); and

the median abdominal girth was 40.0 cm (IQR 38.0–48.0 cm). The median umbilical position in this group of


(IQR -6.00 to -2.04) (Fig. 3). The umbilicus was equi-distant between the xiphoid process and pubis in 25/82

patients (30%) and low-riding in 57/82 patients (70%)

(Table 3). Regarding the male and female subgroup data,the female BMI and torso length were significantly greater

than the male BMI (p = 0.007) and torso length

(p = 0.001); however, when the difference in BMI was

taken into account, the difference in torso length was no

longer significant. There were no significant differences inabdominal girth or umbilical position (Table 4).

All BMI groups

BMI was positively correlated with torso length and

abdominal girth and was negatively correlated with

umbilical position (Fig. 1). When BMI groups were com-pared to each other, the median torso length and median

abdominal girth increased significantly with each BMI

group (normal\ overweight\ obese). In contrast, themedian umbilical position decreased significantly with

each BMI group (normal[ overweight[ obese). Of note,there were too few patients in the underweight group to

conduct a meaningful analysis on these points. The obese

group included a significantly greater percentage of low-riders than the underweight, normal, and overweight

groups. There were no significant differences between the

remaining three groups in regard to the percentage of low-riders.

Fig. 2 Median abdominal dimensions for underweight and normalpatients. For underweight patients, the median torso length was27.7 cm and the median abdominal girth was 27.5 cm. The medianumbilical position was 0.87 cm below the midline. For normalpatients, the median torso length was 31.5 cm and the medianabdominal girth was 29.5 cm. The median umbilical position was0.88 cm below the midline

Table 3 Number of low-riders, equidistant, and high-riders by BMIgroup

Group Low-riders Equidistant High-riders

Underweight 1 5 0

Normal 24 70 2

Overweight 22 53 0

Obese 57 25 0

Fig. 3 Median abdominal dimensions for overweight and obesepatients. For overweight patients, the median torso length was33.0 cm and the median abdominal girth was 32.0 cm. The medianumbilical position was 1.2 cm below the midline. For obese patients,the median torso length was 38.0 cm and the median abdominal girthwas 40.0 cm. The median umbilical position was 3.5 cm below themidline

Table 4 Anatomical distances by BMI group and gender

Group BMI (kg/m2) Torso length (cm) Abdominal girth (cm) Umbilical position (cm)

Underweight females (n = 4) 16.8 (13.8–18.1) 28.0 (26.6–31.3) 25.5 (24.0–29.3) -0.3 (-1.4 to 1.1)

Underweight males (n = 2) 18.3 (18.1–18.4) 27.5 (26.5–28.5) 28.0 (28.0–28.0) -1.5 (-2.3 to -0.8)

Normal females (n = 56) 21.7 (20.0–23.4) 31.5 (29.0–33.0) 29.0 (26.0–32.0) -1.0 (-2.0 to 0.2)

Normal males (n = 40) 22.5 (21.6–23.7) 32.0 (30.0–34.9) 30.0 (28.0–34.3) -0.5 (-2.3 to 0.9)

Overweight females (n = 27) 27.1 (26.3–29.3) 32.5 (30.5–35.0) 32.0 (30.0–38.0) -1.3 (-2.3 to -0.5)

Overweight males (n = 48) 26.0 (25.7–28.2) 33.0 (31.5–35.5) 32.0 (30.0–37.5) -1.4 (-2.4 to -0.3)

Obese females (n = 32) 39.3 (36.3–46.6) 40.6 (37.4–46.3) 42.5 (38.0–50.0) -4.4 (-7.7 to -2.0)

Obese males (n = 50) 33.5 (31.4–40.6) 34.9 (31.5–39.6) 40.0 (38.0–48.0) -3.5 (-5.4 to -2.2)

Data presented as median (IQR); IQR, interquartile range

1998 Surg Endosc (2009) 23:1995–2000

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Ambardar+Surg+Endosc+2009+

Obesity

47

48

Obesity

• LUQ entry • Umbilical insufflation, alternative first puncture trocar site

• Advanced fixation / balloon-tipped trocars

• Port placement

• Trendelenberg “rests” (flatten patient, let out CO2)

• Defer request for steep Trendelenberg until deeper steps (e.g. colpotomy, cuff closure)

• Score posterior colpotomy first

Umbilical entry, alternate entry site

49

Advanced fixation trocars

50

Advanced fixation trocars

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Port placement

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Port placement

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Port placement

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Vessel injury

oblique muscles, where small nervebranches were noted to perforate themuscles. Next, the nerves coursed medi-ally and inferiorly, pierced the internaloblique muscles, and traveled betweenthe aponeuroses of the internal and ex-ternal obliques (Figure 2).

The ilioinguinal nerve pierced the su-perficial or anterior surface of the inter-nal oblique muscle: mean (range), 2.5(1.1–5.1) cm medial and 2.4 (0 –5.3) cminferior to the ASIS. It then coursed me-dially and inferiorly and entered the in-guinal canal at variable distances fromthe pubic tubercles. Along with theround ligament, the ilioinguinal nervewas identified as one of the structuresemerging from the superficial inguinalring in all specimens. The course of thisnerve was traced to the subcutaneous tis-sue of the labia majora and/or monspubis.

The hypogastric (anterior cutaneous)branch of the iliohypogastric nervepierced the anterior surface of the inter-nal oblique muscles 2.5 (0 – 4.6) cm me-dial and 2.0 (0 – 4.6) cm inferior to theASIS. It then coursed medially and infe-riorly and terminated in the subcutane-ous tissue after piercing the aponeurosisof the external oblique.

The closest distance of the ilioinguinalnerve to a point 5 cm superior to the PSand 8 cm from midline was 0.6 (0 –1.6)cm and that of the iliohypogastric nervewas 1.3 (0 –3.7) cm. In the majority ofspecimens, the nerves were just superiorto this point. At a point 2 cm superior tothe PS (typical starting point for trans-verse incisions), the ilioinguinal and ilio-hypogastric nerves were 5.9 (4.0 – 8.3)cm and 3.8 (1.3–5.7) cm lateral from themidline, respectively. In 3 of 11 (27%) ofspecimens, the iliohypogastric nerve ter-minated above the level 2 cm superior tothe PS. In all specimens, the width of thenerves in the anterior abdominal wallwas !2 mm.

Inferior epigastric vesselsFrom their point of junction with the ex-ternal iliacs, the inferior epigastric ves-sels coursed obliquely superiorly towardthe umbilicus. Near the external iliacs,the inferior epigastrics were noted justmedial to the round ligament, as the lig-

ament passed through the deep inguinalring into the inguinal canal.

The closest distance of the vessels tothe midline of the lower abdomen at thepoint 2 cm superior to the PS was 6.1(4.8 –7.9) cm. At this level, the inferiorepigastrics were lateral to the lateral mar-gins of the rectus abdominis muscles inall specimens.

The closest distance of the vessels tothe point 5 cm superior to the PS and 8cm from midline was 3.2 (1.2–5.2) cm.The vessels were medial to this point inall specimens. The line connecting theleft and right ASIS crossed the midline"9 (9.2–10.5) cm superior to the mid-

upper surface of the PS. At the level of theASIS, the vessels were 3.7 (2.6 –5.5) cmfrom the midline of the abdomen.

Surface measurementsWith insufflation of the abdominal cav-ity, the distances moved by points on theskin overlying landmarks of interestwere highly variable. The mean (SD) dis-tance moved by the point 5 cm superiorand 8 cm lateral to the midline PS withinsufflation was 4.4 (8.8) mm medial and8.2 (11.3) mm superior. McBurney pointmoved 8.2 (9.3) mm laterally and 3.1(9.4) mm inferiorly, and the point on theskin overlying the ASIS moved 10.5

FIGURE 1Nerve and vessel locations on anterior abdominal wall

Mean location of ilioinguinal and iliohypogastric nerves and inferior epigastric vessels are shownrelative to anterior superior iliac spine (large open circles); pubic symphysis (PS); point 2 cm superiorto PS, common starting site for Pfannenstiel incisions (dashed line); and point 5 cm superior to PS and8 cm from midline (stars), common landmark for accessory trocar placement.Reproduced, with permission, from Mr Corbyn Beach, Dallas, TX.

Rahn. Anterior abdominal wall nerve and vessel anatomy. Am J Obstet Gynecol 2010.

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234.e3 American Journal of Obstetrics & Gynecology MARCH 2010

Think!of!abdomen!like!a!dome!!Insert!perpendicular!to!the!fascia!

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Rahn+AJOG+2010+

Vessel injury

oblique muscles, where small nervebranches were noted to perforate themuscles. Next, the nerves coursed medi-ally and inferiorly, pierced the internaloblique muscles, and traveled betweenthe aponeuroses of the internal and ex-ternal obliques (Figure 2).

The ilioinguinal nerve pierced the su-perficial or anterior surface of the inter-nal oblique muscle: mean (range), 2.5(1.1–5.1) cm medial and 2.4 (0 –5.3) cminferior to the ASIS. It then coursed me-dially and inferiorly and entered the in-guinal canal at variable distances fromthe pubic tubercles. Along with theround ligament, the ilioinguinal nervewas identified as one of the structuresemerging from the superficial inguinalring in all specimens. The course of thisnerve was traced to the subcutaneous tis-sue of the labia majora and/or monspubis.

The hypogastric (anterior cutaneous)branch of the iliohypogastric nervepierced the anterior surface of the inter-nal oblique muscles 2.5 (0 – 4.6) cm me-dial and 2.0 (0 – 4.6) cm inferior to theASIS. It then coursed medially and infe-riorly and terminated in the subcutane-ous tissue after piercing the aponeurosisof the external oblique.

The closest distance of the ilioinguinalnerve to a point 5 cm superior to the PSand 8 cm from midline was 0.6 (0 –1.6)cm and that of the iliohypogastric nervewas 1.3 (0 –3.7) cm. In the majority ofspecimens, the nerves were just superiorto this point. At a point 2 cm superior tothe PS (typical starting point for trans-verse incisions), the ilioinguinal and ilio-hypogastric nerves were 5.9 (4.0 – 8.3)cm and 3.8 (1.3–5.7) cm lateral from themidline, respectively. In 3 of 11 (27%) ofspecimens, the iliohypogastric nerve ter-minated above the level 2 cm superior tothe PS. In all specimens, the width of thenerves in the anterior abdominal wallwas !2 mm.

Inferior epigastric vesselsFrom their point of junction with the ex-ternal iliacs, the inferior epigastric ves-sels coursed obliquely superiorly towardthe umbilicus. Near the external iliacs,the inferior epigastrics were noted justmedial to the round ligament, as the lig-

ament passed through the deep inguinalring into the inguinal canal.

The closest distance of the vessels tothe midline of the lower abdomen at thepoint 2 cm superior to the PS was 6.1(4.8 –7.9) cm. At this level, the inferiorepigastrics were lateral to the lateral mar-gins of the rectus abdominis muscles inall specimens.

The closest distance of the vessels tothe point 5 cm superior to the PS and 8cm from midline was 3.2 (1.2–5.2) cm.The vessels were medial to this point inall specimens. The line connecting theleft and right ASIS crossed the midline"9 (9.2–10.5) cm superior to the mid-

upper surface of the PS. At the level of theASIS, the vessels were 3.7 (2.6 –5.5) cmfrom the midline of the abdomen.

Surface measurementsWith insufflation of the abdominal cav-ity, the distances moved by points on theskin overlying landmarks of interestwere highly variable. The mean (SD) dis-tance moved by the point 5 cm superiorand 8 cm lateral to the midline PS withinsufflation was 4.4 (8.8) mm medial and8.2 (11.3) mm superior. McBurney pointmoved 8.2 (9.3) mm laterally and 3.1(9.4) mm inferiorly, and the point on theskin overlying the ASIS moved 10.5

FIGURE 1Nerve and vessel locations on anterior abdominal wall

Mean location of ilioinguinal and iliohypogastric nerves and inferior epigastric vessels are shownrelative to anterior superior iliac spine (large open circles); pubic symphysis (PS); point 2 cm superiorto PS, common starting site for Pfannenstiel incisions (dashed line); and point 5 cm superior to PS and8 cm from midline (stars), common landmark for accessory trocar placement.Reproduced, with permission, from Mr Corbyn Beach, Dallas, TX.


Research General Gynecology www.AJOG.org

234.e3 American Journal of Obstetrics & Gynecology MARCH 2010

>!6cm!from!midline!at!or!above!the!ASIS!

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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+2004+

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Vessel injury

Vessel injury

(14.2) mm laterally and 8.8 (8.5) mm in-feriorly. Most importantly, for this finalmeasurement of the position on the skinrelative to the palpable ASIS, the skin al-ways moved in an inferior direction withinsufflation, ranging 1–26 mm.

COMMENTBased on the findings of this unem-balmed female cadaver study, a reason-able region for accessory trocar place-ment in the infraumbilical portion of theanterior abdominal wall is !6 cm fromthe midline at the level of or superior tothe ASIS. Placement of trocars in thisarea minimizes risk of injury to both theilioinguinal/iliohypogastric nerves andinferior epigastric vessels. This cadaverstudy substantiates the recommenda-tions of other studies using computedtomography to guide lateral trocar place-ment for the avoidance of the inferiorepigastrics: Sriprasad et al13 also advo-cates lateral trocars be placed !6 cm

from midline at the level of the ASISs.While our study confirms that place-ment of accessory trocars 5 cm superiorto the PS and 8 cm lateral to the midlineshould prevent inferior epigastric vesselinjury,11 this may increase the likelihoodof ilioinguinal and/or iliohypogastricnerve injury, as both nerves coursed inclose proximity to this surface landmark.

In a previous study by Whiteside etal,14 the ilioinguinal nerve was found toenter the anterior abdominal wall, on av-erage, 3.1 cm medial and 3.7 cm inferiorto the ASIS, and the iliohypogastric en-tered 2.1 cm medial and 0.9 cm inferiorto the ASIS. In our study, we found theilioinguinal emerged through the inter-nal oblique 2.5 cm medial and 2.4 cminferior to the ASIS, and the iliohypogas-tric emerged 2.5 cm medial and 2.0 cminferior to the ASIS. The greatest dis-crepancy between our findings and thoseot Whiteside et al14 was the inferior entrypoint relative to the ASIS. Part of this dis-

crepancy may be due to the exact loca-tion on the ASIS from which measure-ments were taken. However, in bothstudies the nerves were consistentlyshown to emerge at or inferior to thelevel of the ASIS. As the ilioinguinal andiliohypogastrics coursed medially andinferiorly from their entry point in theanterior abdominal wall, low transverseincisions and laparoscopy trocars placedinferior to the level of the ASIS can resultin laceration or entrapment of thesenerves.

Transverse fascial incisions that begin2 cm superior to the PS may compromisethe medial portion of the iliohypogastricnerves if they extend !3.5 cm from themidline. The ilioinguinal nerve and infe-rior epigastric vessels, however, shouldbe spared if these fascial incisions remainwithin 5.5 cm from the midline. Oneshould take care not to place fascial clo-sure stitches lateral to the angle/apex ofthe fascia incision so as to minimize thelikelihood of entrapping these nerves.1,9

Care should also be taken when the lat-eral extents of low transverse fascial inci-sions are directed or “curved” upward.While this practice may prevent injury tothe medial segment of the iliohypogas-tric nerves, it may place the inferior epi-gastric vessels at risk as they course me-dially toward the umbilical region.

In order to avoid inferior epigastricvessel injury during laparotomies, lowtransverse fascial incisions ideally willnot extend beyond the lateral borders ofthe rectus muscles. At a point 2 cm abovethe PS, the inferior epigastrics were al-ways found lateral to the lateral border ofthe rectus muscles. This is the regionknown as Hesselbach triangle, boundedmedially by the lateral border of the rec-tus abdominis muscles, laterally by theinferior epigastric vessels, and inferiorlyby the medial half of the inguinal liga-ment. The locations of the deep inferiorepigastric vessels identified in this studyclosely mirrored those reported in acomputed tomography– based report bySaber et al.5

It should be emphasized that duringaccessory trocar placement, injury to thevessels of the anterior abdominal wall isbest avoided by placing the trocars underdirect visualization. In contrast to the su-

FIGURE 2Course of ilioinguinal and iliohypogastricnerves (n.) in anterior abdominal wall

Near iliac crest, both nerves pierce deep or posterior surface of transversus abdominis muscle (TA).They then course in plane between TA and internal oblique muscles (IO) and then move medially andinferiorly, piercing IO, and travel between aponeuroses of IO and external oblique (EO). Inferiorepigastric vessels are observed lateral to medial umbilical ligaments and just medial to round liga-ments as these enter inguinal canal.Reproduced, with permission, from Mr Corbyn Beach, Dallas, TX.


www.AJOG.org General Gynecology Research

MARCH 2010 American Journal of Obstetrics & Gynecology 234.e4

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repair. Treatment challenges are likely greatest when an injuryoccurs at an outpatient surgical center or at a smaller hospitaldistant from a major medical center.

The objectives of this article was to review the early signsof major vessel injury during laparoscopy and to provide gy-necologists and other surgeons with recommendations fortreating these injuries. Recommended treatment approachesare reviewed for presumed gas embolism in patients whoare either hemodynamically stable or unstable. Treatment ofmajor vessel injury resulting in massive hemorrhage consistsof rapid laparotomy with control of hemorrhage using directpressure until a surgeon experienced in vascular surgery ar-rives. When a major vessel injury occurs in an outpatientsurgical facility distant from a full-service hospital and nosurgeon with vascular experience is immediately available,based on the trauma literature, we recommend temporarycontrol of blood loss using abdominal packing and closure(i.e., ‘‘damage control surgery’’) and judicious resuscitation(i.e., ‘‘damage control resuscitation’’) before transportationof the patient to a medical center [6,7].

Major Vessel Injury during Laparoscopy

Major Vessels of Lower Abdomen and Pelvis

Major arteries that lie in the retroperitoneal space of thelower abdomen and pelvis include the distal abdominal aortaand the common, external, and internal iliac arteries (Fig. 1).In most patients, the aortic bifurcation is located just cephaladto the umbilicus [8]; however, in the thinnest patients, theaorta can lie immediately beneath the umbilicus. At the bifur-cation, the common iliac arteries diverge laterally. In approx-imately themidline, the right common iliac artery crosses overthe left common iliac vein. Near the pelvic brim, the internaliliac artery branches off posteromedially, and the externaliliac artery continues anterocaudally to enter the inguinalcanal.

The major veins lie posterior to these arteries in the lowerabdomen and pelvis. Analogous to the arteries, the vena cavabifurcates into the common iliac veins. These lie almostdirectly behind their associated arteries, whereas the internaland external iliac veins transition to a posteromedial positioncompared to that of the corresponding arteries.

Mechanism of Injury

Veress Needle and Umbilical trocar Injuries

Most retroperitoneal vessel injuries at laparoscopy occurduring blind placement of the Veress needle or primary trocarthrough a periumbilical incision [3]. Based on anatomicalconsiderations, it is likely that the risk of retroperitonealvessel injury is minimized by inserting instruments throughthe umbilicus parallel to the spine in themidline [8].However,the midline can be difficult to accurately determine when thepatient is draped, and the margin of error between successful

intraperitoneal placement and vessel injury can be surpris-ingly small, in particular in thin patients.

A second important variable when inserting periumbilicalinstruments is the angle of insertion. It seems that the risk ofmajor vessel injury can be minimized in most patients byinserting instruments at a 45-degree angle from the plane ofthe patient’s spine [9]. In obese patients, this angle must beincreased to asmuch as 80 to 90 degrees to enter the peritonealcavity; however, the increased distance from the skin to themajor vessels in these patientsmakes this approach reasonablysafe. In patients who are not obese, insertion of instruments atan angle greater than 45 degrees is likely to increase the risk ofmajor vessel injury. In all patients, the insertion angle can onlybe approximated, and placing the patient in the Trendelenbergposition (head down) might increase the risk of placing instru-ments at a greater angle than anticipated in relation to thepatient’s spine [10,11].

Lateral Port Injuries

Major vessel injury can also occur during placement ofsecondary ports. In an effort to avert injuring abdominalwall vessels, trocars for secondary ports are often placed8 cm or farther from the midline [12]. This area, whichapproximates the McBurney point on the right, often liesimmediately anterior to the external iliac vessels. Althoughsecondary port trocars are placed under direct visualization,

Fig. 1. Location of major vessels in relation to umbilicus and pelvic bones.

Average location of the umbilicus below the aortic bifurcation is indicated by

the dashed circle. Major tributaries of the vena cava (i.e., common, internal,and external iliac veins) lie dorsomedial to the major branches of the aorta

(i.e., common, internal, and external iliac arteries).

Sandadi et al. Management of Major Vessel Injury during Laparoscopy 693

Vessel injury

•  Aorta!•  R!common!iliac!artery!•  L!common!iliac!vein!

Sandadai+JMIG+2010+

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• 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

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•  Krishnakumar S, Tambe P. Entry complications in laparoscopic surgery. J Gynecol Endosc Surg. 2009 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. 2012 May;22(4):362-70.

•  Richardson RF, Sutton CJG. Complications of first entry: a prospective laparoscopic audit. Gynaecol Endosc. 1999;8:327–34.

•  Tu FF, Lamvu GM, Hartmann KE, Steege JF. Preoperative ultrasound to predict infraumbilical adhesions: a study of diagnostic accuracy. Am J Obstet Gynecol. 2005 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. 2014 May;123(5):1049-56

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•  Nezhat CH, Dun EC, Katz A, Wieser FA. Office visceral slide test compared with two

perioperative tests for predicting periumbilical adhesions. Obstet Gynecol. 2014 May;123(5):1049-56

•  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. 2012 Nov-Dec;19(6):701-7.

•  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. 2009 Dec;24(12):3057-62

•  Brezina PR, Beste TM, Nelson KH. Does route of hysterectomy affect outcome in obese and nonobese women? JSLS. 2009 Jul-Sep;13(3):358-63.

•  O'Hanlan KA, Lopez L, Dibble SL, Garnier AC, Huang GS, Leuchtenberger M. Total laparoscopic hysterectomy: body mass index and outcomes. Obstet Gynecol. 2003 Dec;102(6):1384-92.

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•  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. 2009 Sep;23(9):1995-2000.

•  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. 2010 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. 2004 Jul;17(5):400-8.

•  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. 2003 Jul;80(1):209-12.

•  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. 2010 Nov-Dec;17(6):692-702

access to the peritoneum and avoiding complications...ahmad+cochrane+2015! 6 entry techniques •...

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