OBGYN.net: Frontiers in Reproductive Medicine

ABOUT THE EDITOR

TABLE OF CONTENTS

Adhesion Formation and Prevention
Danielle Luciano, MD

In Vitro Fertilization (IVF) & Assisted Reproduction Techniques (ART)
by Ruth Lathi, MD and Barry Behr, PhD, HCLD

Operative Office Hysteroscopy
accompanying video: Hysteroscopic Polypectomy
by Keith Isaacson, MD and Aarathi Cholkeri, MD

Less Invasive is Best
accompanying video: Laparscopic Hysterectomy
by Resad Paya Pasic M.D.,Ph.D and Royshanda C. Smith, MD

Hysteroscopic Sterilization
by Radha Syed, M.D., F.A.C.O.G.
Assisted by Adrienne L. Ligouri, MSIII

Update on Management of Uterine Fibroid
by Togas Tulandi, MD and Nadia Kabli, MD

The dilemma of endometriosis: is consensus possible with an enigma?
by Camran Nezhat, MD, Eva D. Littman, MD, Ruth B. Lathi, MD, Bulent Berker, MD, Lynn M. Westphal, MD, Linda C. Giudice, MD, PhD and Amin A. Milki, MD

Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles
by Eva Littman, MD, Linda Giudice, MD, Ruth Lathi, MD, Bulent Berker, MD, Amin Milki, MD, and Camran Nezhat, MD

The Evolution of Down Syndrome Screening and the FASTER Trial
by Lauren Ferrara MD and Joanne Stone MD

OBGYN.net

A Novel Device for Peritoneal Access in Laparoscopic Surgery

Linda M. Nicoll MD^a, Madelein Lemyre MD^ab, Dorian Bosev MD^ac, Jian Qun Huang MD^a, Lisa Bhagan MD^a and Camran Nezhat MD^a

a) Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, CA, USA
b) Department of Obstetric and Gynecology, Faculty of Medicine, Laval University, Quebec, Quebec, Canada
c) Department of Obstetrics and Gynecology, Faculty of Medicine, Medical University of Sofia, Maichin Dom Hospital, Sofia, Bulgaria

2. Needle First

The appropriate Veress needle is again selected based on the patient’s body habits. The needle is advanced through the LapCap needle pass-through port up to a point 1-2cm beyond the lower edge of the LapCap. The needle is held in place by turning the needle pass-through port knob in a clockwise direction until it is locked. The LapCap is then placed on the patient’s abdominal wall with the needle tip touching the patient’s skin close to or just under the umbilicus. No incision is necessary. Of note, in very thin patients very little of the Veress needle (<5cm) should protrude from beyond the rim of the LapCap dome.

Sterile suction tubing is then connected to the LapCap vacuum line port and standard suction is applied. The suction will elevate the full thickness of the abdominal wall into the device dome, thereby advancing the needle through the abdominal wall and into the cone shaped vacuum space created within the LapCap dome. Confirmation of intra-abdominal placement and insufflation are then carried out in a manner identical to the method described above.

3. Alternative Insertion site

For some patients with a history of midline laparotomy or a high likelihood of dense periumbilical adhesions, abdominal entry at a site distant from the umbilicus may be desired. We have used this instrument in the left upper quadrant and subxiphoid area successfully under these conditions. Again, mapping is recommended prior to primary trocar placement.

Our Experience

Using the LapCap, we achieved successful abdominal entry in all patients in whom the technique was attempted. On average, we required only one passage of the needle and the vast majority of entries were successful at first attempt. Although an opening pressure of up to 15 mmHg always reflected proper placement in our patients, some patients had a higher opening pressure (up to 20mmHg) and were nevertheless proven to have undergone successful placement of the Veress needle.

The cause of higher pressures in our cohort have been investigated and linked to causes including an inadvertently closed Veress needle, kinked gas tubing, contact with a large uterus, extraperitoneal placement, or proximity to either the omentum or an intraabdominal adhesion. Those situations help explain few cases requiring more than one application of the needle.

It should also be noted that higher initial abdominal (opening) pressures are to be expected with using the LapCap as opposed to those encountered when practicing conventional entry with the Veress needle. These initial pressure readings are not necessarily reflective of the actual intra-abdominal pressure, but of the pressure within the small dome-shaped cavity created by the LapCap, as evidenced by the fact that the intra-abdominal pressure reading drops dramatically (almost half) when the LapCap suction is turned off upon initially reaching 20 mmHg.

At this time, given our findings of successful entry with patients with opening pressure readings up to 20 mmHg and in all patients up to 15 mmHg, we feel comfortable considering pursuing insufflations with an opening pressure less than or equal to 17 mmHg, and possibly higher depending upon our clinical judgment.

It should also be noted that the vacuum-first method is now our preferred method of use. We find that the technique offers a greater sense of control during entry with the Veress needle. While we find this method particularly helpful when teaching practitioners who are already familiar with other techniques of elevating the abdominal wall prior to attempted entry with the Veress needle, we find that the increased sense of precision increases even seasoned LapCap users comfort level as compared with the needle-first method.

The ‘bottom line,’ however is safety. In over 135 patients, we have had no retroperitoneal or vascular injuries. Neither have we had any patients experience skin trauma (ecchymosis or punctures) apart from the Veress entry site. However, the limitations of our experience include the fact this small series did not include enough patients to show a significant difference in the small rate of vascular injuries associated with conventional use of the Veress needle (estimated to be around 0.3/1000 cases.4-7)

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