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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
8
2.1 Three-Dimensional Optics in Clinical Practice
1
2
2
1
4
3
Fig. 2.1.3 Dual-channel angled endoscope. Visualization of an object in
the frontal projection produces a familiar horizontal 3-D image.
1 Fiberoptic cable
2 Endoscope
3 Camera head
4 Monitor
due to the limited two-dimensional visual impression. For this
reason various mechanical aids such as clips, staplers, knot
pushers, etc., some of them very expensive, have been
developed to circumvent these problems. In contrast, three-dimensional technology returns the surgeon to the skills and
abilities required of any surgeon who uses a stereoscopic operating microscope.
In these and similar situations the 3-D system reveals its advantages to the experienced user. Particularly for complex and extensive operations such as colorectal surgery, gastric fundoplication, or selective proximal vagotomy, the 3-D visualization
significantly simplifies operative techniques and reduces the
duration of the operation. The stereoscopic image demonstrates
even the smallest neurovascular structures, providing good spatial resolution and magnification. It requires a lesser degree of
cognitive integration, which the surgeon perceives as less exhausting. It is possible to reconstruct the third dimension under
two-dimensional visualization. For this reason the lack of spatial projection is not always apparent when an experienced surgeon performs a relatively simple operation where good expo-
sure can be obtained. Yet many persistently occurring complica-
tions in routine laparoscopic operations such as cholecystectomy are often attributable to insufficient exposure of the
operative site or lack of anatomic orientation. In situations such
4
3
Fig. 2.1.4 Dual-channel angled endoscope. Rotating the viewing angle
tips the horizon trace.
1 Fiberoptic cable
2 Endoscope
3 Camera head
4 Monitor
as these three-dimensional imaging technology aids even the
experienced surgeon and contributes to the safety of the procedure.
Disadvantages of the Three-Dimensional
System
The more complicated the technology the more intensive are
the required properative preparations. Complexity demands extensive familiarity with the procedure and equipment; there is a
learning curve for the operating room crew also.
Due to inherent limitations, 3-D imaging can only approximate
the normal sensory impression produced by the human eye. It
can recreate the eye’s overall optical performance within a
limited range.
If the video frequency rate is too low, double images will occur
and longer operations will produce headaches. Distortions attributable to improper stereoscopic adjustment will produce
the same effect. The shutter eyeglasses required to produce the
binocular image restrict the field of vision and significantly
darken it. This is particularly disconcerting to surgeons with
normal eyesight who are not used to eyeglasses and it can cause
certain problems. Active shutter eyeglasses are equipped with a
battery and are appreciably heavier. This is an annoyance during
longer procedures.
Two cameras are always required to produce a stereo image of
adequate quality. The chip camera systems are relatively small.
In spite of this the camera head and the optical system will nec-
essarily be larger and heavier in the 3-D system than those used
in standard two-dimensional systems. A basic design disadvan-
tage of the dual-channel angled laparoscope is that the horizon
tracing is tipped whenever an object is viewed from the side as
mentioned earlier. The results are disorientation and malaise
which the 3-D system was intended to reduce in the first place.
The 3-D system requires greater illumination and therefore a
more powerful light source. The depth of focus of the three-dimensional images is extreme and the three-dimensional compression sometimes appears unrealistic as a result. Whereas the
human eye only images three-dimensional objects in focus in
the central beam, the 3-D optical system will also reproduce unimportant marginal objects with great clarity. This can irritate
the surgeon. Yet situations may occur during the operation in
which this apparent disadvantage can become an advantage.
Often it is difficult to visualize the point of interest in the exact
center of the image. The greater depth of focus permits the sur-
geon to work safely under stereoscopic control even when he or
she is forced to work at the edge of the visual field.
Preparation
9
The Ideal System
The ideal 3-D system currently consists of a rotating singlechannel angled laparoscope connected to two separate cameras
via an optical interface. The frequency-transformed image is
displayed on a monitor with an active polarizing attachment.
The matching shutter eyeglasses with polarizing filters function
passively. Optimum light efficiency is achieved by using a xenon
source and fiberoptic cable with low attenuation.
Summary
Two-dimensional optical visualization has previously been a
significant disadvantage of videoendoscopic operative procedures. This disadvantage has been assessed differently by
various surgeons. The greater the experience of the individual
surgeon and his or her cognitive integration and ability to think
in three dimensions, the easier it is to compensate for the lack of
the third dimension. The more complex and demanding the
operation, the more important and helpful three-dimensional
visualization becomes. This technology opens up new possibilities and perspectives for both the beginner and the experienced
laparoscopic surgeon.
2.2 Access and Exposure Techniques in Laparoscopic Surgery
L. Galibert, D. B. Earle, F. M. Steichen, G. Stringel
Preparation
Time spent preparing is time well spent. Minimally invasive
techniques should proceed in a deliberate, planned fashion.
Patience is the key; haste makes waste at best, and may result in
disaster at worst.
The Patient
The patient must have a complete history and physical examination, and be mentally as well as physically (nothing by mouth
for at least 8 hours, void on call) prepared for the procedure as
well as any possible changes in approach (open). A gastric tube
or Foley catheter (for longer or selected pelvic procedures) may
be placed. The appropriate area is adequately prepared, with
particular attention given to the umbilicus (Fig. 2.2.1). Pneu-
matic sleeves to prevent deep vein thrombosis are applied to
the lower extremities. Antibiotics are administered if indicated.
Positioning
The OR table must be mobile and flexible, to facilitate position
changes of the patient and coordination with the monitors. The
patient is secured to the table (straps, shoulder braces) with
adequate padding and protection to safely undergo position
changes. The arms are tucked, as their presence extended to the
sides makes some procedures virtually impossible to perform. If
the lithotomy position is used, the hip joint should be as minimally flexed as possible to maintain maximum working space.
Fig. 2.2.1 Thoroughly disinfect the umbilicus with a small swab prior to
the regular skin preparation to decrease the umbilical infection rate.
Positioning the awake patient may avoid extremes of position.
The video monitors are placed to afford the most direct view to
reduce strain.
Equipment
Equipment for laparoscopic as well as open procedures must be
readily available and properly functioning (Table 2.2.1). A recording device should be available (Table 2.2.4, page 23).
10
2.2 Access and Exposure Techniques in Laparoscopic Surgery
Preoperative Precautions
1. Assure table tilt mechanism is functional. Table & joints level, kidney
rest down.
2. Consider using foot board and extra safety strap.
3. Position patient properly on O. R. table for cholangiography.
4. Assure notification of radiology technologist with time estimate.
5. Assure proper mixing and dilution of cholangiogram contrast solution for adequate image. For surgeons utilizing fluoroscopy for
cholangiography, the patient should be placed on a table capable of
supporting this task and appropriate shielding should be available.
6. Assure availability of Foley catheter and N/G tube.
7. Assure all power sources are connected and appropriate units are
switched “on”. (Don’t use multi-socket single source or the circuit will
overload.)
8. Assure adequate volume of compressed gas (at insufflator and pressure irrigator). Backup full tank must be available.
9. Assure insufflator alarm is set appropriately. Assure tight connection
between insufflator tubing and Luer-lock adapter.
10. Assure full volume in irrigation fluid container . . . (recheck during
case).
Table 2.2.1 SAGES laparoscopy trouble-shooting guide.
Problem Cause Solution
1. Poor Insufflation/loss
of pneumoperitoneum
2. Excessive pressure Veress needle or cannula tip not in free peritoneal cavity Reinsert needle or cannula
required for insufflation (initial or
subsequent) Port stopcock turned off Fully open stopcock
3. Inadequate lighting
(partial/complete loss)
4. Lightning too bright Light is on “manual-maximum” Go to “automatic”
5. No picture
on monitor(s)
6. Poor quality picture
a. fogging/haze
b. flickering, electrical
interference
CO2tank empty Change tank
Accessory port stopcock(s) not properly adjusted Inspect all accessory ports. Open or close stopcock(s)
Leak in sealing cap or stopcock Change cap or cannula
Excessive suctioning Allow time to reinsufflate
Loose connection of insufflator tubing at source or at port Tighten connections
Hasson stay sutures loose Replace or secure sutures
Tubing disconnection from insufflator Connect tubing
Flow rate set too low Adjust flow rate
Occlusion of tubing (kinking, table joints, etc.) Inspect full length of tubing. Replace with proper size
Patient is “light” Give more muscle relaxant
Cannula tip not in peritoneal space Advance cannula under visual control
Loose connection at source or scope Adjust connector
Light is on “manual-minimum” Go to “automatic”
Bulb is burned out Replace bulb
Fiber optics are damaged Replace light cable
Automatic iris adjusting to bright reflection from
instrument
Monitor brightness turned down Readjust setting
Room brightness floods monitors Dim room lights
“Boost” on light source is activated Deactivate “boost”
Monitor brightness turned up Readjust setting
Camera control or other components (V.C.R., printer,
light source, monitor) not “on”
Cable connector between camera control unit and/or
monitors not attached properly
Cable between monitors is not connected Cable should run from “video out” on primary monitor
Input select button on monitor doesn’t match “video in”
choice
Condensation on lens from cold scope entering warm
abdomen
Condensation on scope eyepiece, camera lens, coupler
lens
Moisture in camera cable connecting plug Use suction or compressed air to dry out moisture (don’t
Poor cable shielding Replace cables as necessary
Insecure connection of video cable between monitors Reattach video cable at each monitor
11. Check the electrosurgical unit; make sure auditory alarm of machine
is functioning properly and the grounding pad is appropriate for the
patient.
12. Check Veress needle for proper plunger/spring action and assure easy
flushing through stopcock and/or needle channel.
13. Assure closed stopcocks on all ports.
14. If utilizing the gasless technique, assure that the operating room
table has side arms capable of supporting the abdominal lift unit and
that appropriate blades for the unit are available.
Scrub Tech/RN Duties
15. Check sealing caps for cracked rubber, stretched openings.
16. Check to assure instrument cleaning channel screwcaps are in place.
17. Assure free movement of instrument handles and jaws.
18. If Hasson cannula to be used, assure availability of stay sutures and
retractors. Check valves, plunger, spring, and seals on reusable Hasson cannulae.
19. Assure adequate printer film and video tape if documentation is
desired.
20. Periodically send scissors and reusable trocars for sharpening.
as needed
as necessary
Re-position instruments, or switch to “manual”
Make sure all power sources are plugged in and turned
on
Cable should run from “video out” on camera control
unit to “video in” on primary monitor. Use compatible
cables for camera unit and light source
to “video in” on secondary monitor
Assure matching selections
Gently wipe lens on viscera; use anti-fog solution, or
warm water
Detach camera from scope (or camera from coupler),
inspect and clean lens as needed
use cotton tip applicators on multi-pronged plug)
Move electrosurgical unit to different circuit or away
from video equipment
Table 2.2.1 SAGES laparoscopy trouble-shooting guide (continued).
Problem Cause Solution
c. blurring, distortion Incorrect focus Adjust camera focus ring
Cracked lens, internal moisture Inspect scope/camera, replace if needed
Too grainy Adjust enhancement and/or grain settings for units
with this option
7. Inadequate suction/
irrigation
8. Absent or “weak”
cauterization
Society of American Gastrointestinal Endoscopic Surgeons, 2716 Ocean Park Blvd, Suite 3000, Santa Monica, CA 90405
Phone: +1 (3 10) 3 14-2404, Fax: +1 (310) 3 14-25 85, E-mail: sagesmail@aol.com, WWW: http://www.sages.org/
Occlusion of tubing (kinking, blood clot, etc.) Inspect full length of tubing. If necessary, detach from
instrument and flush tubing with sterile saline
Occlusion of valves in suction/irrigator device Detach tubing, flush device with sterile saline
Not attached to wall suction Inspect and secure suction & wall source connector
Irrigation fluid container not pressurized Inspect compressed gas source, connector, pressure
dial setting
Patient not grounded properly Assure adequate grounding pad contact
Connection between electro-surgical unit and instrument
loose
Foot pedal or hand switch not connected to eletrosurgical unit
Wrong output selected Correct output choice
Connected to the wrong socket on the electrosurgical unit Check that cable is attached to endoscopic socket
Instrument insulation failure outside of surgeon’s view Use new instrument and inspect insulation
Inspect both connecting points
Make connection
Exposure
11
Anesthesia
Most procedures are performed under general anesthesia.
Epidural, spinal, or local anesthesia may be used in certain cir-
cumstances. These forms of anesthesia require a cooperative
patient. Use of nitrous oxide to obtain pneumoperitoneum and
decreasing insufflation rate and amount extend these applications. However, one should use nonelectrical methods of dissection and hemostasis to avoid the 320 °C combustion threshold
of nitrous oxide. The ultrasonic scalpel coagulates and dissects
by rapidly vibrating at 55,000 times/second while remaining at
a temperature of less than 80 °C.
Exposure
Pneumoperitoneum
Pneumoperitoneum is the most commonly used method to ob-
tain exposure of the peritoneal cavity. Gasless laparoscopy is
thoroughly addressed elsewhere in this text. Generally, carbon
dioxide is insufflated at a high rate (up to 15 liters per minute)
to a pressure limit of 12−16 mm Hg, however, adjustments are
made for age, size and as intraoperative monitoring dictates
(Table2.2.2). A variety of methods of initiating pneumoperi-
toneum is available.
Experimental studies have shown that alterations in the physiological environment of the peritoneal cavity may explain post-
operative shoulder pain. Potential causes are the temperature of
the gas used for the pneumoperitoneum as it leaves the storage
cylinder (usually 20 °C), irritation of the diaphragm due to
muscular distension as well as chemical reactions by gas on the
peritoneum. The patient should be warned preoperatively that
he/she may experience shoulder pain (around 25% of all
patients) that will subside spontaneously within 2 to 3 days
without analgesic treatment.
The Open Method
The open placement technique was first demonstrated in the
United States by Hasson in 1975, and in Germany by Koenig in
1979. It is the safest method of initial port placement. Its use is
not limited to the initial port placement; any number of ports
Table 2.2.2 Pressure guidelines.
Age group Pressure range Insufflation rate
Infant 4−6 mmHg less than 1 liter/minute
Child 6−8 mmHg
Adult 12−16 mmHg less than 15 liters/minute
can be placed using this technique at any location in the abdomen. Some prefer to use this technique in selected cases such as
slender, muscular patients, those with prior abdominal procedures, or pediatric patients. The initial port is usually placed
at the umbilicus (Fig. 2.2.2a,b), as this is the thinnest part of the
abdominal wall even in muscular or obese patients. If the
patient has had a previous midline incision, the second most
commonly accepted area to place the initial port is the left
upper quadrant. However, placement off the midline in an
obese individual can be dauntingly difficult, or require an excessively large incision. The patient should be supine for initial port
placement to keep intraabdominal contents distant from the
abdominal wall. Once the pneumoperitoneum is established,
the patient may be repositioned for the procedure.
Placing the incision within the umbilicus yields the most cosmetic scar. A supra- or infraumbilical incision is made at the surgeon’sdiscretion,some opting to incise on the side of the umbilicus closest to the operative field (Figs. 2.2.3a, b to 2.2.5).
Entry into the peritoneal cavity may be confirmed visually, by
gently placing a closed clamp in all directions and meeting no resistance, or by palpation with the little finger. The Hasson
cannula is placed into the peritoneal cavity, and secured into
place by wrapping the previously placedsutures around “wings”
especially designed for this purpose, or with inflation of an attached balloon retention tip (Fig. 2.2.6). By placing the endo-
scope into the cannula but not through it, proper placement can
again b e confirmed prior to insufflation.
The Hasson technique is particularly helpful in patients who
have had multiple previous abdominal operations, in whom the
risk of adhesions is increased. However, all operations do not
lead to adhesions, nor do adhesions follow previous operations
only. In some cases, the adhesions may be so extensive as to require conversion to laparotomy. Although initially more time
consuming, open placement takes no longer once one becomes
12
2.2 Access and Exposure Techniques in Laparoscopic Surgery
a
Fig. 2.2.2a,b The umbilicus may be grasped on either side using towel clips. The skin is incised approximately one and a half centimeters in length, in
a curvilinear, midline, or transverse manner depending of the lie of the skin folds.
a
Fig. 2.2.3a, b The subcutaneous tissues are bluntly dissected and the junction of the base of the umbilicus and the anterior fascia is grasped with a
Kocher clamp and elevated.
b
b
adept at this technique, and closing also becomes a much simpler, quicker procedure.
The Veress Needle
Prior to blind placement of the Veress needle or trocars into the
peritoneal cavity, the bladder and stomach are emptied, and the
aorta palpated to decrease the chance of injury. The snap mechanism of the Veress needle is checked. A skin incision large
enough to fit the ensuing trocar is made and the subcutaneous
tissues are bluntly dissected down to the anterior fascia.
Generally, the spring mechanism will snap three times as the
Veress needle penetrates the fascial layers and the peritoneum,
while all resistance disappears once the peritoneal cavity is
entered (Fig. 2.2.7). A number of tests have been devised to confirm placement in the peritoneal cavity. Although no one test is
infallible, the accuracy increases with the number of tests
passed (Figs. 2.2.8 to 2.2.10).
The insufflation tubing may then be attached and started on low
flow. The patient pressure reading should be low (well under
10mm Hg) with free flow of the gas and symmetric insufflation
of the abdominal cavity. This serves as further confirmation of
proper placement. A “visual Veress needle” is also on the market
which further confirms proper placement using a thin endo-
scope which fits through the needle.
Once the trocar is introduced, with correct placement confirmed by the endoscope, the insufflation tubing is reconnected.
If the pressure prior to trocar placement was set at 25 mm Hg,
reset it down to less than 15 mm Hg (Fig. 2.2.11 a, b).
Sharp Trocar Placement without Prior Pneumoperitoneum
Some surgeons advocate simple blind trocar placement with
manual countertraction on the abdominal wall without prior
pneumoperitoneum. Although they quote a similar complication rate to other techniques, we are reluctant to condone this
technique if only due to our lack of familiarity with it.
Complications
Complications of the Veress needle or blind placement techniques include vascular, gastrointestinal, urological, and gynecological trauma, as well as damage to solid organs. Although
less frequent, these complications are not eliminated by using
the open technique. If initial attempts to prevent or treat complications are unsuccessful, immediate cessation of the operation or conversion to laparotomy should be performed
(Figs. 2.2.12 a, b and 2.2.13).
Complication: Improper placement of the Veress needle
(Fig. 2.2.14 a , b)
If one is not initially convinced of proper placement due to failing one or more of the above mentioned tests, one or two additional attempts at placement may be made, then the open
placement technique should be undertaken.
Exposure
a
13
Fig. 2.2.5 The peritoneum is then grasped and elevated between two
clamps and incised.
b
Complication: High pressure reading
If one is certain of proper placement but the pressure reading is
too high, other causes include water in the tubing, closed valves,
kinking of the tubing, or inadequate relaxation of the patient.
Fig. 2.2.6 Hasson cannula with wings to secure with suture, or (not
shown) cuff and inflatable balloon.
14
2.2 Access and Exposure Techniques in Laparoscopic Surgery
Fig. 2.2.7 One hand applies traction on the towel clips or directly re-
tracts the abdominal wall. With the application of gentle controlled pressure, the needle is placed perpendicularly through the anterior abdominal
wall with the dominant hand resting on the abdominal wall holding the
needle not at the handle, but slightly closer to the tip. This method pre-
vents sudden uncontrolled entry into the peritoneal cavity.
b
a
Fig. 2.2.8 The Veress needle should be freely mobile through
360 degrees.
Fig. 2.2.9a, b (a) Injected saline flows freely. (b) Aspiration is freely ac-
complished returning neither blood nor enteric contents.
Complication: Carbon dioxide embolus
Prevention: Use the lowest insufflation pressure compatible
with adequate visualization, reduce operating time, release
pneumoperitoneum when not actively working.
Treatment: Evacuate pneumoperitoneum, left lateral decubitus
position, 100% oxygen, aspiration through central venous catheter, if catheter was previously placed.
Fig. 2.2.10 The “slurp” test − A drop of saline placed in the closed Veress
needle should flow freely once the needle is opened, especially if the
abdominal wall is lifted.
Complication: Deep vein thrombosis
Prevention: Use antithrombic pneumatic sleeves on lower extremities, low dose heparin prophylaxis, keep pneumoperitoneum insufflation pressure and duration to a minimum.
[1 l/min]
0 mm/Hg
10 mm/Hg
Exposure
15
High flow
a b
Fig. 2.2.11 a, b Once the abdominal cavity is adequately insufflated (between 15 and 25 mm Hg), the needle is removed, and a sharp trocar placed
with countertraction on the towel clips or by directly grasping and lifting the abdominal wall.
14 mm/Hg
18 mm/Hg
30 mm/Hg
a
Fig. 2.2.12a, b Complication: Piercing the greater omentum with the
Veress needle. This can cause bleeding or produce interstitial emphysema
of the greater omentum, pushing it against the anterior abdominal wall
with insufflation.
Prevention: Make sure the abdominal wall is lifted during insertion of the
Veress needle. Advance the tip less than one cm after the last audible
snap of the Veress needle, rotate the needle and perform the safety tests.
Complication: Cardiopulmonary compromise
Prevention: Keep insufflation pressure and time to a minimum,
proper patient selection.
Treatment: Evacuate pneumoperitoneum, cease procedure if
not too far advanced, convert to laparotomy if necessary, ade-
quate fluid resuscitation.
b
Treatment: This complication is often recognized only after inserting the
endoscope. Once recognized, withdraw the trocar to the level of the peritoneum then gently tap the abdominal wall from the outside to return the
omentum to its original position. Control of omental bleeding can usually
be performed laparoscopically.
Complication: Postoperative shoulder or subphrenic pain
Carbon dioxide is irritating to the peritoneum. Warming the gas
to body temperature as it is insufflated, and taking care to
completely evacuate the peritoneal cavity may decrease pain.
Other gases such as nitrous oxide have anesthetic properties on
the peritoneum, however potential danger of combustion limits
their widespread use.
Regardless of the mode, once access is obtained, the first step is
to inspect the peritoneal cavity to rule out iatrogenic injury.
16
2.2 Access and Exposure Techniques in Laparoscopic Surgery
a
Fig. 2.2.13 Complication: Puncture of a hollow organ with the Veress
needle. The “slurp” and rotation tests are generally not successful in this
situation.
Prevention: Do not insert the Veress needle near laparotomy scars. Pay
strict attention to all positioning tests.
Treatment: If you can bring the trocar back into the peritoneal cavity, an
attempt to remove the carbon dioxide by aspiration through a fine needle
may be made with laparoscopic repair of the injury. If unsuccessful, con-
version to laparotomy is indicated.
Potential Space Exposure
In certain circumstances minimally invasive surgery is contemplated in an area where no space actually exists. Such areas include the preperitoneal “space” for hernia repair and urologic
procedures, the retroperitoneal space for neurologic, vascular,
orthopedic, or urologic procedures, and the subfascial plane in
the leg for vascular procedures. A variety of balloon dissectors
are available (not shown). The procedure for entering the preperitoneal space will be describe d, however the principles of
this technique may generally be applied to any area.
An infraumbilical incision is made as previously described. The
base of the umbilicus is grasped with a Kocher clamp and elevated and the anterior fascia is cleared lateral to the linea alba
on the side of interest. The chance of entering the peritoneal
cavity is reduced by incising the anterior sheath over the rectus
muscle (Fig. 2.2.15a, b).
The rectus muscle is retracted laterally and the balloon dissector advanced to the symphysis pubis (Fig.2.2.16 a, b). No re-
sistance should be encountered during these maneuvers.
Occasionally the ridge on the shaft of the balloon dissector will
need extra pressure to pop it through the fascial opening. The
introducer is then removed without advancing or retracting the
balloon dissector, making sure to maintain the proper orientation since the balloon inflates laterally and will not function
properly if turned sagitally (Fig. 2.2.17).
The balloon should remain fully inflated for a few minutes to
allow tamponade of any traumatized small vessels. The balloon
b
Fig. 2.2.14a, b Complication: Preperitoneal insufflation.
Cause: a) Placement of the Veress needle at too great an angle, b) trocar
sliding out into the preperitoneal space.
Prevention: a) Place Veress needle perpendicularly and pass all tests, b)
place trocars securely and check placement prior to insufflation.
Treatment: Replace Veress needle or trocar, secure trocar with an additional fascial suture, convert to open procedure, allow time for resolution.
is then deflated (slowly, under direct visualization, if desired)
and removed with the valve open to prevent air trapping in the
balloon with resultant trauma. The space is then reentered, retracting the rectus muscle with the S-shaped retractor, and the
Hasson cannula placed. The retractor and clamp are then removed, and the Hasson secured with previously placed fascial
sutures, a threaded grip or (as we prefer) a cannula with inflatable balloon and cuff (Fig. 2.2.18 ).
Complication: Hemorrhage
Prevention: completely retract all strands of rectus muscle laterally and cauterize any visible vessels.
Complication: Uneven inflation
If the balloon inflates unevenly, or more dissection is needed
unilaterally, manual pressure on the contralateral abdominal
wall with further inflation of the balloon is sometimes of benefit.
Complication: Violation of the peritoneal cavity
Prevention: incise anterior sheath laterally over the rectus
muscle, direct balloon dissector anteriorly when advancing it.
Treatment: (a) suture defect closed and attempt placement on
contralateral side, (b) avoid defect and continue with procedure
(pressure generally equalizes with minimal loss of working
space, (c) if pneumoperitoneum interferes, place Veress needle
or flexible angiocatheter into peritoneal cavity as a vent.
Preperitoneal Space Exposure
17
a
Fig. 2.2.15a, b (a) A longitudinal incision approximately one centimeter
in length is made in the anterior sheath and the medial leaf grasped with a
clamp. (b) The rectus muscle is then completely retracted laterally using
Fig. 2.2.16a, b (a) Once the rectus muscle is retracted, a balloon dissec-
tor is placed behind the rectus and the retractor removed. The clamp
should remain in place until the Hasson cannula is inserted.
b
S-shaped retractors. Any muscle fibers left medially will likely be damaged
in the ensuing dissection and will lead to bleeding. Visible vessels are
likewise cauterized to minimize trauma and bleeding.
(b) The dissector is directed anteriorly down to the symphysis pubis to
avoid puncturing the peritoneum. The tip of the dissector should be ad-
vanced all the way down to the symphysis and then directed slightly post-
erior.
Fig. 2.2.17 The camera is then inserted, and the balloon slowly inflated
under direct vision.
Fig. 2.2.18 After removal of the deflated balloon, the Hasson cannula
with balloon tip and cuff is placed and the preperitoneal “space” insuf-
flated.