Access to the Abdominal and Thoracic Cavity
Safe establishment of a pneumoperitoneum is of paramount importance in minimally invasive surgery. Gas insufflation of the abdominal cavity is necessary to create sufficient working space by suppressing the viscera and elevating the abdominal wall. Variou
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Access to the Abdominal and Thoracic Cavity H. Jaap Bonjer and Jan Wolter A. Oosterhuis
3.1
Access to the Abdominal Cavity
Safe establishment of a pneumoperitoneum is of paramount importance in minimally invasive surgery [1]. Gas insufflation of the abdominal cavity is necessary to create sufficient working space by suppressing the viscera and elevating the abdominal wall. Variously shaped retractors inserted through a small incision and connected to a lifting device have been employed to elevate the anterior abdominal wall and avoid use of gas. However, this technique, gasless laparoscopy, does provide inferior exposure compared to a pneumoperitoneum, and, therefore, has been largely abandoned. Carbon dioxide is the most frequently used gas for insufflation because it is not combustible, readily absorbable and low in cost. However, carbon dioxide insufflation does cause acidosis in the exposed tissues and is associated with suppression of macrophage function. Surprisingly, humidification of the insufflated carbondioxide and warming the gas to body temperature are rarely used in spite of the damaging effect of cold and dry gas on the peritoneum that has been observed at electron microscopy. The insufflation pressure needs to be calibrated according to the required exposure and kept as low as possible to limit the reduction of venous return and microcirculation. High insufflation pressures can be due to incomplete muscular relaxation while low pressures combined with high insufflation flow indicate leakage along or through trocars, open stopcock or detachment of the insufflator tubing. It is recommended to lower the insufflation pressure at the end of the procedure to identify any bleeding from venules.
H.J. Bonjer, MD, PhD, FRCSC (*) • J.W.A. Oosterhuis, MD, PhD Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands e-mail: [email protected]; [email protected]
3.2
Closed, Hybrid and Open Techniques
A pneumoperitoneum can be established in a closed, semi- closed and open fashion. The choice of first entry is important to place the laparoscope at a site which will provide a good laparoscopic view for the laparoscopic procedure and to avoid adhesions due to previous surgery. The umbilicus is preferred for acquiring access to the peritoneal cavity given its central position in the abdomen and because the abdominal wall is thinnest at the umbilicus. In case of a former midline incision including the umbilicus, it is advisable to choose an entry site more laterally and withstand the temptation to re-use the scar for cosmetic reasons. The closed method employs the use of the spring loaded Veres needle (Fig. 3.1). This needle is inserted blindly into the peritoneal cavity while the abdominal wall is elevated manually or by graspers placed on the skin to increase the distance between the abdominal wall and the viscera and vessels. The tactile sensation of two ‘pops’ due to penetration of fascia and peritoneum aids the surgeon to determine the position of the tip of the Veres needle.
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