The proper hardware and instruments are essential for performing a safe laparoscopy. Most large medical centers have one or several dedicated interventional laparoscopic operating rooms. Although not essential, it centralizes the hardware used for these procedures. This enables the nursing staff to become more familiar with the hardware and instruments used.

1. POWERED OPERATING ROOM TABLE

Using an electric or powered operating room table is a definite asset. In most cases, the surgeon has to frequently change the position of the patient in order to enhance exposure and visualization.

2. LAPAROSCOPIC SYSTEM

These components include a high resolution monitor, a camera and video signal enhancer, a light source and a cord. Optional equipment includes a printer and/or a video cassette recorder.

• High Resolution Monitor: A Main and a Slave Monitor are used for most procedures. The usual size is 19 inches.
• Camera and Video Signal Enhancer:

This is the system we have used the most. Although we are still using earlier generations of their video camera, their latest generation of Video Camera (Three Chips and higher) has proven to be one of the best systems available. We are now also using a STRYKER Model 882TE system which appears to be a very competitive model.

Light Sources and Light Cord: A 300-watt xenon light source is usually used. The light was transmitted via flexible, fiberoptic bundles connecting the light source to the telescope. The operator and the nursing staff should always be aware the light cords have a limited life span. When a significant decrease in light delivery is noted, the surgeon should verify the majority of the fiber optics are functional.

• High Flow Electronic Insufflator: The CO2 pump should be a High Flow insufflation pump with a low flow and a high setting. This insufflator should be capable of delivering a maximum gas flow of CO2 of 9.9 L/min. These insufflators are electronically equipped to monitor, maintain and control a constant intraabdominal pressure between 12 and 18 mm Hg. The inflow tubing is connected to the insufflation port of the machine and to a V connector that is attached to two different trocar insufflation ports for better and faster insufflation. A CO2 gas filter should be used between the pump and the trocar. Before every laparoscopy, the tubing system should be flushed with CO2 for at least one minute.

Creation of the Pneumoperitoneum

• Using a Veress Needle

We always create the pneumoperitoneum using a disposable Veress Needle or an Auto Suture SURGINEEDLE*. We have totally disregarded reusable Veress Needles. Potential catastrophes have occurred on our surgical service when the spring of the resusable Veress needle malfunctioned transforming the Veress needle into an uncontrolled harpooning device. In addition, we continue to question the sterility of these reusable needles.Veress needles come in two lengths (120 cm and 150 cm); the longer version is obviously for obese patients. We are however always able to create a pneumoperitoneum with a short Veress needle in these patients. The hospital no longer stocks the longer version, as we rarely use it.

The Technique

1. Preparation of the Abdomen: The entire, anterior abdominal wall should be prepped from mid thigh to the nipple line and as lateral as possible. Laparoscopic procedures can occasionally become very difficult and may require the insertion of additional trocars away from the original operating site.

2. Grounding the Patient: All patients, without exception, should be properly grounded.

3. Insertion of the Veress Needle: The safest access into the intraabdominal cavity with a Veress needle is the subumbilical area. The anterior abdominal wall is the thinnest at this level and all fascial layers are fused into single fascial planes. Thus, the operator should always attempt to insert the Veress needle at this site in the virgin abdomen.

• STEP 1: Elevating the Anterior Abdominal wall: The anterior abdominal wall needs to be elevated in order to distance it from the intraabdominal contents. This is done by grabbing the abdominal wall directly under the umbilicus with one hand. If the patient is overweight, two towel clamps can be used on each side of the umbilicus to achieve the same result.
• STEP 2: The Incision: A 1 mm incision is made with a # 11 Scalpel below the umbilicus.
• STEP 3: Checking the Instruments and Inserting the Veress Needle: The spring function or the retraction capability of the Veress Needle is checked. The operating table should be in neutral or flat position. The needle is then slowly inserted into the incision. It is angled toward the pelvis and advanced. The operator should feel or sense the needle passing through two distinct planes.

The needle is advanced and withdrawn several times. If this is done easily and without obstruction, the tip is in proper position.

• STEP 4: The Saline Test: Although we no longer perform this test routinely, all neophytes laparoscopic surgeon should do so. Ten cc of normal saline is injected. This should be done easily. The abdominal pull is then released. The Veress needle is then filled to the rim with normal saline (or a open syringe can be used). The tension on the skin is resumed and the level of saline should immediately drop if the needle is in proper intraabdominal position.
• STEP 5: Initiating the Insufflation: The Veress needle is then connected to the CO2 insufflation tubing (a filter should be used). Insufflation is initiated at a low flow. Intraabdominal pressure recorded at this point should not exceed 8 mm Hg. Entry pressure at low flow should be checked immediately while the abdominal wall is still elevated. If higher, move the needle around or resume the pull on the skin or anterior abdominal wall. If the pressure is too high, the Veress needle it is not in the right position and needs to be removed. Begin again.

If in place, switch to high flow and inflate the intraabdominal cavity.

• With a Blunt Trocar or BLUNTPORT* Trocar (Hasson Type Cannula) for the Scarred Abdomen

The blunt trocar is used to safely create a Pneumoperitoneum in the scarred abdomen. It is inserted by making an initial skin and a fascial incision. The fascial incision should be 1 to 1.5 cm in size. A long suture (2.0) is placed on each fascial edges. With finger dissection a tunnel or an opening into the intraabdominal cavity is gently created. The BluntPort* is then inserted. The foamgrip anchoring device is set and secured with the previously placed suture. The insufflation port is connected to the insufflation tubing and the pneumoperitoneum created.

• With a VISIPORT* OPTICAL TROCAR for the Scarred Abdomen

Insuflate the abdomen prior to the insertion of the VISIPORT* OPTICAL TROCAR. A 1 cm skin incision is made with a plain scalpel. A telescope is inserted into the VISIPORT OPTICAL TROCAR* and the path of entry of the VISIPORT OPTICAL TROCAR* into intraabdominal cavity is visualized. The VISISPORT OPTICAL TROCAR* is advanced slowly through the different planes of the abdominal wall. These planes are cut slowly with the blade of the VISIPORT OPTICAL TROCAR* (at the tip of the instrument) until the intraabdominal cavity is reached. Pneumoperitoneum must be created or abdominal wall elevation must be performed prior to the insertion of the VISIPORT* OPTICAL TROCAR..

Maintaining the Pneumoperitoneum

A laparoscopy can be performed without significant, deleterious effect with intraabdominal pressures up to 20 mm Hg. However, some laparoscopic inguinal hernia repairs require higher pressures in the 18 and 20 mm Hg. range to achieve necessary additional exposure.

Our guidelines are clear.

• The best operating intraabdominal pressures are between 10 to 15 mm Hg. The visualization of this type of intraabdominal pressure can be further enhanced by modifying the patients’ position (operating table position to Trendelenburg to reverse, etc.)
• Higher pressures in the 15 to 20 mm Hg range are suboptimal. There is a definite correlation with increased postoperative patient discomfort and recovery and the use of increased intraabdominal pressure.
• Pressures beyond 20 mm Hg are classified as dangerous with potential hemodynamic and pulmonary compromise and long term effects on the intraabdominal wall musculature. When such pressures are used, some patients will actually report increased abdominal girth and a bloating post-operative feeling which persisted for months after the procedure in spite of intensive exercise.

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