Introduction

Laparoscopy is one of the most common surgical procedures performed in the United States today. It is the modality of choice for many physicians for removal of ectopic pregnancy, bilateral tubal sterilization, treatment of endometriosis, lysis of adhesions, cholecystectomy, appendectomy, splenectomy, prostatectomy, etc.  It is becoming increasingly popular for more complex procedures, including laparoscopic hysterectomy and myomectomy.

It has been shown that one in three complications of laparoscopic surgery occur during the set-up phase of laparoscopy, which includes the creation of pneumoperitoneum and initial trocar entry.¹  More specifically, over 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase.^2-7 

Therefore, it is of utmost importance to choose a method of entry which minimizes risk of injury to the patient.  No clear advantages have been demonstrated from the available modalities for abdominal entry.  Closed entry techniques, which include use of the Veress needle or direct trocar insertion to establish pneumoperitoneum, have not been shown to have advantages over one another, nor over open entry with the Hasson technique.⁸ 

Nevertheless, closed entry with the Veress needle is the most popular method of entry for gynecologic laparoscopists.⁸  About 96.3 % of gynecologic laparoscopies in the United States are initiated by insertion of Veress needle for creation of pneumoperitoneum.⁹ Although this method of entry is generally considered to be safe, Veress needle injuries to numerous abdominal structures have been reported.¹⁰

The rate of major injury from peritoneal entry with the Veress needle is reported at 0.9/1000 cases.7 Rates of entry-related bowel and vascular injury were 0.4/1000 and 0.2-0.4/1000 cases, respectively, with the Veress needle technique.^4-7  Although major vascular injury is rare, it carries significant risk of major morbidity or death.¹²

The risk of injury increases dramatically with repeated attempts at entry. ^{14, 15}  The reported first pass failure rate of the Veress needle is 14.5 %.^{13, 14} The reported risk of needle- related injury after the second attempt increases to between 16.3% and 37.5% with even higher rates reported with subsequent attemtps.^{13, 14} These types of complications are dangerous for the patient, frustrating to the surgeon and costly to the hospital. Certainly, the introduction of a device which aids in safe and successful Veress needle entry into the abdomen is a welcome addition to the surgeon’s armamentarium.

Recently, a new method for Veress needle insertion has been introduced which has the potential to increase first-pass Veress needle insertion rates and decrease rates of retroperitoneal vascular injury.   This new pneumoperitoneum creation assist device (PCAD) is named LapCap (Aragon Surgical, Inc. Palo Alto, CA). It is designed to assist in blind Veress needle insertion.  It also obviates the need for a surgeon to employ the use of an assistant or to apply penetrating clamps to the patient’s skin to aid in elevation of the abdominal wall.  Furthermore, it has the potential to reduce operator-depenency and increase automaticity in standardizing a method of safe entry into the peritoneal cavity.

The safety and efficacy of LapCap was first studied in a pilot group of 48 women.¹⁷ In all patients, pneumoperitoneum was achieved with first passage of the Veress needle and no injuries were reported.  We have been using LapCap since early 2007 and present to you our experience with the device and hope to share our recommendations with your readers.

continue to page 2

We encourage readers to email us with their comments and questions.