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2. Complications in G

necological Oncolog

uce

ect on t

ut moti

postoperative

, an

uce

rom

osis ris

, as we

as exce

ent postoperative ana

esi

Good postoperative care, with access to correctl

staffed hi

ependenc

and/or intensive care

In t

neco

ica

onco

center, t

e anest

etist is an inte

part o

iscip

inar

team

Infecti

n gyneco

ogica

onco

ogy, patients are at ris

ection in t

e c

est, in

e pe

vis/intraa

omina

region, in t

e urinary tract, at t

e woun

site, an

at sites o

intravenous an

arteria

ines. Any prop

actic regime is e

ective

in re

ucing postoperative in

ective comp

ications [7]. It is important t

at t

regime

e given at t

e appropriate time. We

ave use

a nurse-

ase

“patient

group

irective” to ensure t

at a

women un

ergoing surgery, w

er e

tive or emergency, are covere

y anti

iotic prop

axis. As t

e majority o

our patients are more t

an 60 years o

, we avoi

e use o

cep

osporins,

as t

is can pre

ispose towar

pseu

omem

ranous co

itis [8]. Our patients

receive metroni

azo

e (500 mg IV), gentamicin (120 mg IV), an

enzy

peni-

in (1.2 g IV) wit

uction o

anest

esia. We omit t

e penici

in i

patient is a

ergic. We see very

ew cases o

est in

ection in our group

ue to t

e use o

regiona

anest

esia an

active pre- an

postoperative

ysiot

erapy

hrombos

atients with

necolo

ical cancer are at increased risk of thrombosis

resultin

from the mali

nanc

and the effects of pelvic sur

. Man

patients

have had decreased mobilit

prior to sur

as a result of massive ascites. The

ascites, combined with a

elvic mass, which can com

ress the venous return

from the le

s, causes the woman with

necolo

ical cancer to present a special

risk for thromboembolism. In addition, man

women with

necolo

ical

cancer have a morbidl

increased bod

mass index and thus are at risk of

embolism. Followin

necolo

ical oncolo

sur

, the incidence of deep

vein thrombosis without proph

laxis is in excess of 40% [9]

herapeuticall

, a number of

necolo

ical oncolo

patients are takin

ents that lead to an increased risk of thromboembolism. While conventional

hormone replacement therap

(HRT) is well known to predispose to throm

boembolism, patients taking tamoxifen have a greater risk of thrombosis

and are therefore advised to stop takin

it 2 weeks before sur

. This

oint is im

ortant, as there is an increased number of breast cancer

atients

who opt for sur

ical ablation of their ovaries as part of their breast cancer

mana

ement

https://t.me/med1917

4 R

e use

ow-mo

ecu

ar-wei

eparin (40 m

cutaneous

) on a

asis. T

is re

imen is

iven at 18:00

ours on a

mission an

so wi

not inter

ere i

an epi

ura

is use

owin

mornin

. In a

ition, patients wear

uate

stoc

ings an

are we

rate

. We pre

er to use regiona

anest

sia in addition to the general anesthesia, as this has the positive beneﬁ

t o

ucin

rom

osis. Ca

stimu

ation is a

so use

in t

e operatin

eater,

although the evidence for this procedure’s beneﬁ

t is not conc

usive. We con-

inue t

ow-mo

ecu

ar-weig

eparin unti

e patient is

isc

arge

rom

ita

In patients with signiﬁ

cant deep vein thrombosis, we also consider using

an inferior vena caval umbrella ﬁ

lter inserted under radiological control. Its

se great

y re

uces t

e ris

ata

monary em

us, w

is especia

en t

ere is

atera

iac venous t

rom

osis associate

wit

a pe

vic

ass.

emorrha

e and Transfusio

During extensive surgery for advanced malignancy, patients are at signiﬁ

ant ris

or intraoperative or primary

oss. We routine

y crossmatc

nits o

or patients un

ergoing ovarian cancer surgery. Wit

patients

ergoing interva

ing surgery, we o

ten anticipate an anemia

ue to

e cancer an

e e

ect o

emot

erapy. Patients wi

ten

e trans

use

e operation starts. Our anest

etic team pre

ers t

is to trans

usion on t

rior to t

e operation. As t

ese patients are operate

on in t

e win

etween

es o

emot

erapy, we

o not

ay t

e patient as one mig

o ot

atients wit

anemia

or a

enign operative in

ication. Secon

ary

emorr

age

ccurs rare

y an

is usua

y associate

wit

a s

ippe

igature or unrecognize

ing point. O

ten t

ere is a

arge raw area

owing tumor resection, an

we ﬁ

nd that lavage with hot (30˚C–40˚C) water (not saline) allows identiﬁ

ca-

ion o

ing points

ortunate

y, we

o not

ave easy access to eryt

ropoietin

or our c

erapy patients in t

e NHS. T

is su

cutaneous treatment can

e use

aintain t

emog

uring c

emot

erapy an

uce t

e nee

or trans

usion prior to interva

ing surgery.

Dama

e to Or

adical

necolo

ical sur

aims to remove as much of the disease as

equired, including a margin of normal tissue. In cervical cancer surgery, this

eads to Wertheim’s approach, whereb

the ureter, bladder, and bowel are

dissected free from the cervical cancer. The incidence of ﬁ

stula rate is reported

s between 1% and 6% for this surgery. During lymphadenectomy, there is a

isk of major vessel damage. Vascular injury associated with lymphadenec-

https://t.me/med1917

2. Complications in G

necological Oncolog

tom

in en

ometria

cancer occurre

in 0.7% o

e cases;

owever, t

is was

atis

actori

mana

rou

equate sur

ica

trainin

experience o

wit

in t

e unit [10]. Durin

ovarian sur

, t

isease is usua

lly

con-

ﬁ

ned to the peritoneal cavity, and signiﬁ

cant remova

isease can

e ac

ieve

peritonea

strippin

. Recta

resection wit

primar

anastomosis

or c

ear

ance o

vic

isease is a

vocate

some. T

e accepta

eve

or anasto

motic

e equiva

ent to t

or recta

surgery. In t

e cancer center,

ave access to many specia

ists w

o can provi

e intraoperative a

vice

an in

. T

is is ver

en consi

erin

uries, w

ortunate

y are very rare

oun

iscence an

ernias are re

ative

y uncommon

ut are associ

ate

wit

cancer cac

exia an

ine incisions

sycholog

cal Compl

cat

he patient dia

nosed with

necolo

ical cancer often responds b

wantin

ever

thin

possible done to remove the cancer. While a postmeno

pausal woman, who has completed her reproductive life, ma

view a h

terectom

as the removal of an or

an that has “turned bad,” a

oun

woman

have a ver

different viewpoint. This is especiall

marked for those

women whose dia

nosis is made throu

h screenin

. The woman dia

nosed

throu

h screenin

has never had an

mptom or si

n of the disease and

relies on the medical service for makin

the dia

nosis as well as treatin

the cancer. The patient then has to live throu

h the life-threatenin

illness,

with major surgery and recovery, never having been “sick” in the ﬁ

lace.

lthou

h the ma

orit

of women with

necolo

ical cancer have alread

completed their families or are postmenopausal, a small

roup of

oun

necolo

ical cancer patients still have fertilit

needs. This situation is also

pertinent for those patients with breast cancer. Preservation of fertilit

poten

tial can pose a signiﬁ

cant

roblem. Germ cell ovarian cancer can be treated

with conservative sur

, as this disease needs treatment with chemotherap

Reco

nition of the potential of this condition is imperative, as

erm cell

ovarian cancer is associated with a

oun

roup and an overall better

urvival rate. As there has been a tremendous increase in cervical intrae

ithe

lial neoplasia (CIN), a number of

oun

women are requirin

man

cervical

treatments. Excisional treatments to the cervix lead to earlier deliver

. Con

ideration must be

iven to assisted fertilit

techniques for collection of

ooc

tes or embr

os for these

oun

women, althou

h there is often limited

eat

adical vulval sur

is associated with severe chan

es to bod

ima

This has prompted the move to the triple incision, with which we tr

to reduce

the morbidit

of the traditional radical en bloc vulvectom

. We aim to perform

a wide local excision with a 2 cm macroscopicall

clear mar

in from the tumor.

This reliabl

leaves an 8 mm patholo

icall

clear mar

in, which is associated

https://t.me/med1917

minima

ris

oca

recurrence. T

e in

uino-

emora

enectom

results in a signiﬁ

cant risk of lymphedema, which is ugly and has its associated

omor

. In t

e ear

postoperative perio

, woun

is compro-

ise

ection an

/or

ormation o

sts in 20%–30% o

patients,

e in t

term,

ema o

s wit

increase

ris

or ce

itis

s re

orted in 10%–70% of

atients

exua

unction

een measure

in up to 80% o

women un

oin

neco

ica

cancer sur

[11]

ow to Reduce Compl

cat

ons Furthe

omplications associated with

necolo

ical cancer sur

can be reduced

addressin

several areas of practice, startin

with the patient and leadin

hrou

h aspects of the disease, operation, sur

eon and his or her team, and

herap

hrou

h education, patients can be advised about disease-reduction activ-

. In

necolo

ical cancer, this is the use of the oral contraceptive pill for

ears, which leads to a 50% reduction in ovarian cancer risk, albeit with an

increased risk of cervical cancer. The use of tamoxifen leads to a signiﬁ

reduction in breast cancer, but its long-term usage is associated with a signiﬁ

eased

atase

inhi

or breast cancer will lead to much less endometrial disease. U

take of a

te screenin

methods that have been validated is important. We have seen a

signiﬁ

cant reduction in cervical cancer since the active call/recall system for

ervical screenin

primar

care was introduced in 1988. Cervical cancer has

ecome a rare cancer in the last decade in the United Kin

dom, a situation that

as not

een mirrore

in t

e rest o

Western Euro

e. T

e ro

e o

arosco

roph

lactic bilateral oophorectom

for patients at hi

h risk of

eneticall

arried ovarian cancer is im

ortant. The use of

readmission assessment is vital

o allow the anesthetist to have access to the

atient several weeks

rior to the

peration. The patient’s ph

sical state can be optimized before sur

The approach to the disease can be modiﬁ

ed in several ways. The use of

etter ima

allows the sur

eon to be full

aware of the extent of the disease.

his ma

lead to anticipation of and preparation for bowel sur

both

he sur

eon and the patient. It ma

modif

the need to operate, as, if more

xtensive

isease is

iscovere

on ima

, we ma

consi

er ra

iot

erap

ervical cancer or neoad

uvant chemotherap

for patients with extensive

varian cancer. T

e use o

e “ris

-o

-ma

nanc

ex” [12]

een

dated

cases

r wh

s a survival advanta

e for the patient. We use a cutoff of 200 for the risk-of-

ali

nanc

index and have found it to be ver

effective. Neoad

uvant chemo-

herap

separate out those patients who are chemotherapeuticall

esistant, and therefore we operate onl

on those patients who have chemo-

ensitive disease. This a

ain allows for the patient’s condition to be optimized.

ith the effect of chemotherap

, the ascites disappears and the cachexia often

mproves. We have active input from dieticians, and patients who are havin

https://t.me/med1917

2. Complications in G

necological Oncolog

difﬁ

culties with nutrition are given early support, which may include paren-

ot operatin

is per

aps t

est wa

ucin

operative comp

ications.

We screen our patients wit

postmenopausa

wit

transva

ina

tra

oun

. T

ose patients wit

in re

ar en

ometrium

o not un

o an

further investi

ation. This population amounts to more than 40% of the

patient

roup, an

we avoi

e ris

operative intervention (re

atin

outpatient

steroscop

)

or t

ese patients. T

a misse

cancer

is ver

sma

<<1%. T

e ro

e o

enectom

in en

ometria

cancer is

ein

resse

e Me

ica

Researc

Counci

, a stu

in t

e treatment o

ometria

cancer (MRC ASTEC). T

is ran

omize

stu

een reporte

in abstract form, suggesting that there is no beneﬁ

t from extended surgery.

e use o

a secon

proce

ure in ovarian cancer is not genera

y recom-

mended, as the results of this operation do not inﬂ

uence t

e surviva

[

]

. A

uce

rate o

owe

resection is seen wit

primar

ovarian cancer sur

as it does not appear to give any survival beneﬁ

t. This theory, however, has

not

een su

ect to a contro

tria

. Wit

e increase in more ear

-sta

cervica

cancer seen as a resu

t o

e screenin

pro

ram, we can per

orm

ess

radical surgery. Typically, the Rutledge type 2 radical hysterectomy is sufﬁ

cient

or treatment rat

er t

an t

e type 3. T

e type 2 proce

ure gives a simi

uccess rate wit

ower comp

ication rate. T

e use o

erti

ity-sparing surger

(ra

ica

trac

ectom

) is more appropriate wit

sma

er-vo

ume cancers. T

e o

sentine

-no

issection is o

interest

or patients wit

cancer.

Wit

y 10%–20% o

e patients wit

apparent stage 1/2

isease

aving

positive nodes, the sentinel-node technique reduces the signiﬁ

cant morbidity

or t

ose wit

e-ne

ative

isease. In a

ition, t

is proce

ure

reat

uces t

operation an

ospita

sta

, two parameters t

at are

important

or t

e e

y patient

e va

ue o

e mu

iscip

inary meeting cannot

e overemp

asize

e mana

ement o

ucin

comp

ications. An important ro

e in t

e meetin

is t

at o

e specia

ist pat

ogist, w

o provi

es in

ormation

ing to eit

more or

ess extensive surgery. As we

as in

orming t

e team a

out t

urgery, t

e pat

ogica

opinion may a

vise wit

respect to t

e nee

juvant t

erapy or o

servation a

one wit

out

urt

er t

erapy.

aparoscopic sur

as not

een use

onco

centers in t

Unite

Kin

om. Our experience is t

or en

ometria

cervica

cancer,

there are quite considerable beneﬁ

ts for minimal-access techniques relating to

iagnosis an

recovery wit

no a

verse e

ects

air o

e mi

ine a

omina

incision s

use a mass-c

osure tec

nique wit

ong-

asting a

sor

e or nona

sor

oope

suture. Less

pain is associate

wit

ong-

asting a

sor

e suture. Repair o

incisiona

ernia is

est ac

ieve

wit

mes

[14]

aving t

e rig

t surgeon

or t

e operation is very important. T

e success

e operation is

etter in centers wit

requency o

proce

ure.

Surgery in t

is setting a

ows t

e uti

ization o

a surgeon w

ose is appropri

ate

y traine

, anot

actor

ing to

etter outcomes. Junor et a

. [15]

emonstrate

at an operation

or ovarian cancer per

orme

y a gyneco

ogi

onco

ist was associate

wit

a 25%

etter outcome

or a

vance

isease

https://t.me/med1917

than an operation performed by the generalist; this translates into a signiﬁ

can

survival advantage. This ﬁ

nding is in addition to the patient being managed

e mu

iscip

inar

team an

receivin

e appropriate c

emot

erap

e use o

osexua

support usua

lly

via a specia

ist nurse w

ccess to a

itiona

expertise is ver

in a

eviatin

patients’ ps

ess.

Return to theater is a problem that occurs but is difﬁ

cult to quantify. Early

eturn to t

eater

or an appropriate reason can

e savin

. It is essentia

ere

ore, t

at t

e postoperative care

or t

e patient is o

qua

n t

e West An

ia Cancer Networ

, we are usin

eocon

erencin

ows

or t

e interaction o

oca

unit–

eve

team wit

e s

ecia

ist

iscip

inary team at t

e center. T

s to

etter

iscussion an

man

gement

or patients wit

cancer an

precancer wit

out requiring t

at patients

r c

inicians trave

to t

e center

ncl

neco

ica

cancer sur

is associate

wit

comp

ications, some o

are avoi

ectin

e correct operation, sur

eon, an

ospita

or t

e proce

ure. Ot

er comp

ications may

e re

uce

y optimizing t

atient’s con

ition

ore sur

mana

e patient in specia

ist

its.

erences

1. NHS Execut

ve. Improving Outcomes in Gynaecological Cancers—The Manual.

ondon: NHS Executive; Jul

1999

2. Bristow RE, Tomacruz RS, Armstron

DK, Trimble EL, Montz F

. Survival effect of

axima

tore

uctive sur

or a

vance

ovarian carcinoma

urin

e p

ati

num era: a meta-ana

sis.

in Onco

2002

;

–

3. S

JH. Revise

FIGO staging

or gynaeco

ogica

cancer. Br J O

stet G

naeco

1989

;

:889–892.

4. Shepherd JH, Ngan HY, Neven P, Fryatt I, Woodhouse CR, Hendry WF. Multivariate

analysis of factors affecting survival in pelvic exenteration.

nt J Gynecol Cancer.

1994

1–370

5. Wi

ht R, Baldock M.

eport from the Working Party on Co-Morbidity Assessment

n Cancer—Its Role in the National Core Cancer Dataset

Exeter, En

land: NHS

Information Authorit

; 2001

6. Arbous MS, Grobbee DE, van Kleef JW, et al. Mortalit

associated with anaesthesia:

a qua

itative ana

sis to i

enti

ris

actors. Anaest

esia. 2001;56:1141–1153.

7. Guasc

ino S, De Santo D, De Seta F. New perspectives in anti

iotic prop

hyl

axis

or o

stetric an

gynaeco

ogica

surgery. J Hosp In

ect. 2002;50(supp

A):S13–S16.

https://t.me/med1917

2. Complications in G

necological Oncolog

8. Al-Eidan FA, McElnay JC, Scott MG, Kearney MP. Clostridium difﬁ

–

assoc

ated

iarr

oea in

ospita

ise

patients.

in P

arm T

er.

2000

;

101

–

109.

9. Cran

on AJ, Koutts J. Inci

ence o

post-operative

eep vein t

rom

osis in

nae

ogica

onco

ogy. Aust N Z J O

stet G

naeco

. 1983

;

23:21

–219.

10. Nunns D, Wi

iamson K, Swaney L, Davy M. T

e mor

ity o

surgery an

juvant

iot

erapy in t

e management o

ometria

carcinoma. Int J G

neco

Cancer.

2000;10

233

–

238

11. Andersen BL

an Der Does J. Surviving gynecologic cancer and coping with sexual

orbidit

: an international problem.

nt J Gynecol Cancer.

994;4:225–241

12. Tin

ulstad S, Ha

en B, Sk

eldestad FE, Halvorsen T, Nustad K, Onsrud M. The risk-

f-mali

nanc

index to evaluate potential ovarian cancers in local hospitals. Obstet

neco

999;93:448–452

nce surviva

in epit

ovarian cancer.

ancet.

988;8611:599–603

14. Luijen

RW, Hop WC, van

en To

MP, et a

. A comparison o

suture repair wit

mes

air

or incisiona

ernia. N Eng

J Me

2000;3

392

–

398.

15. Junor EJ, Hole DJ, McNulty L, Mason

Young J. Specia

ist gynaeco

ogists an

surviva

outcome in ovarian cancer: a Scottis

nationa

stu

y o

1866 patients. Br J

bstet Gynaecol

1999

;

:1130–113

https://t.me/med1917

. Laparoscopic Entr

echni

ues: Consensus

avita Lalchandan

Kevin Phillips

Once relatively conﬁ

ned to obstetrics and gynecology, laparoscopic proce-

ures t

ave

een

eve

ope

or a

s o

surgery wit

in t

e a

omen

ave increased dramatically over the past decade. The attraction of laparos

opy, as opposed to the “open” operational equivalent, to the gynecologist and

eneral sur

eon is the reduced trauma of access. Several ver

small incisions

re utilized rather than one large laparotomy incision. There is clear evidence

that laparoscopic surgery provides signiﬁ

cant beneﬁ

ts compared with lapa-

rotomy for patients, providers, and surgeons. Potential beneﬁ

ts for patients

include reduced total operative trauma, reduced incidence of major wound

esive comp

ications, more rapi

conva

escence, an

aster return to

work or usual activities. The beneﬁ

ts for healthcare providers include shorter

hospital stay with consequent hospital costs and social costs. The beneﬁ

ts for

urgeons include an almost-closed and no-touch operative approach with

reduced risk of infection, better display of anatomy and pathology, more

precise removal of diseased tissue, and more accurate tissue repair [1–4]. As

with an

sur

ical procedure, the laparoscopic approach is associated with

complications, which must be offset against the expected clinical beneﬁ

ts.

larger medical and surgical community is still evaluating the safety and effec-

tiveness of these laparoscopic procedures in comparison to the traditional

open surgical procedures [2,5–7]

George Kelling has been credited with the ﬁ

rst laparoscopy as we know it

today. In 1901 he used a Fiedler puncture needle to introduce ﬁ

ir in

the peritoneal cavity (pneumoperitoneum) of a live canine that was locall

anesthetized. Kelling then inserted a trocar into the abdomen and used the

trocar to advance a Nitze c

stoscope (used as an earl

laparoscope) to visuall

inspect the canine abdominal cavit

[8,9]

Until recently, laparoscopic surgery was conducted primarily in the ﬁ

eld

of gynecology. Laparoscopic tubal sterilization was ﬁ

rst described in the 1930s

and 1940s, but it was not until the late 1970s that operative endoscopic tech-

niques were used to treat endometriosis and infertility [10,11]. Progress in the

development of new instruments, optics, lasers, and electrosurgery enabled

e per

ormance o

y comp

ex an

sop

isticate

aparoscopic surger

8,10,12

]

https://t.me/med1917

3. Laparoscopic Entr

Techniques: Consensus 2

t was on

ter t

eve

opment o

computer-c

ip vi

eo/te

evision

camera that in 1985 the ﬁ

rst laparoscopic cholecystectomy in a human was

per

orme

in German

, succee

its in

epen

ent intro

uction in France

in 1987 [9]. T

ese a

vances were

owe

e rapi

expansion o

aparos

cop

into a

areas o

enera

sur

. As Ste

ato writes, “It can

e sai

wit

out

exa

eration that almost an

abdominal or retro peritoneal operation per

orme

‘open’

een attempte

aparoscopica

lly

” [8].

n t

e Unite

States, 310,756

aparoscopic c

stectomies were per

orme

in 1997. Dia

nostic

aparoscop

was estimate

ave occurre

91,170 cases, an

arosco

ic steri

ization was estimate

ave occurre

17,961 women [13]. In Austra

ian

ospita

etween Ju

1999 an

June 2000,

more t

an 5.5 mi

ion surgica

proce

ures were un

erta

en. O

ese, near

% were estimate

ave occurre

aparoscopica

y—a tota

151,501

apa

roscopic procedures. These ﬁ

gures suggest that even with small complication

rates,

e num

ers o

patients wi

er a comp

ication.

aparoscop

c Entr

Techn

que

he ma

orit

of complications associated with laparoscopic sur

occur

during access and the creation of artiﬁ

cial

neumo

eritoneum [14–18]. The

umbilical area is the thinnest

ortion of the abdominal wall and is therefore

the preferred access site [12]. However, immediatel

below this point are the

aortic bifurcation, the bowel, and the omentum. Access-related in

uries can

occur to these or

ans as well as to the inferior vena cava, liver, portal vein,

stic arter

, ureter, bladder, iliac arter

, and epi

astric arter

[12,19]. Ma

vascular injuries are rare [11], but once they are inﬂ

icted

between 9% and 13%

of patients will die, often as a consequence of hemorrha

e or

as embolism

[20,21]. Access-related bowel or visceral in

uries are more common. Reports

indicate that between 50% and 66% of bowel or visceral in

uries are undia

nosed at the time of primar

sur

and can lead to ma

or complications such

as se

sis or

eritonitis [11].

Class

cat

on of Laparoscop

c In

Laparoscopic entry-related injuries can be classiﬁ

groups:

pe 1 in

urie

—dama

e b

Verres needle or trocar to normall

located

ood

esse

pe 2 in

uries

—

dama

e b

Verres needle or trocar to bowel adherent

abdo

min

l w

It is recognized that when bowel is ﬁ

rmly adherent to the anterior abdominal

wall at the point of entr

into the cavit

, then bowel dama

e ma

occur

https://t.me/med1917

2 S. Lalchandani and K. Philli

er t

e mo

e o

access is

aparotom

(open) or

aparoscop

ose

espite t

e rapi

evo

ution in an

option o

aparoscopic sur

in t

ast

eca

enera

sur

eons, most case reports an

e series reportin

ese in

uries are

erive

rom o

neco

iterature. Even wit

newer

nstrumentation and knowled

e, these in

uries still occur with

reat frequenc

n part t

is ma

ate to a

earnin

curve associate

wit

e a

option o

aparoscopic sur

ut a

itiona

actors inc

e a

erstan

e mec

anisms invo

in creatin

ese in

uries an

apprecia-

ion

or t

e proximit

important viscera

structures to t

e anterior a

omi-

nal

all.

There are ﬁ

ve access methods in three major categories. There is consider-

abl

ate as to w

ese access met

s is t

e sa

est an

/or most

eff

ective.

. B

ose

met

Needle (Verres or other) insertion into peritoneum, followed b

gas insufﬂ

ation, insertion of trocar, and insertion of la

aro

sco

e. Both insertions are conducted in a blind fashion in closed

laparoscop

, usuall

at an infraumbilical site or in the pit

ili

cus.

Thi

ost

access

necolo

Direct trocar insertion into peritoneum, followed b

as insuf

ation and insertion of laparoscope. The rationale for the devel-

opment of this approach was the difﬁ

culty associated with

raspin

the wall of an abdomen distended b

pneumoperito-

neum, alon

with the safet

issues related to the concomitant

increase in force required to insert the primar

trocar [22]. A

further beneﬁ

t of this method was the ability to inspect the

trocar insertion site for both position of the trocar and dama

to internal or

ans prior to introducin

pneumoperitoneum

[13]. The Z technique for dia

nostic laparoscop

is a variation

on the direct trocar techni

ue [12].

. Visual/o

en method

Hasson technique, includin

peritoneal cutdown followed b

insertion of Hasson trocar under direct visualization

secured

with a purse-string suture or stay suture, and then insufﬂ

with carbon dioxide

[

11,12,23,24

3. H

brid visual/closed method

Optical trocar to gain access, followed by gas insufﬂ

insertion of la

arosco

Optical needle to gain access, followed by gas insufﬂ

ation

inser

tion of trocar, and insertion of laparoscope.

Pneumoperitoneum is desi

ned to facilitate better visualization of the abdomi-

nal cavit

durin

laparoscopic sur

. It is formed when carbon dioxide

is introduced into the peritoneum through controlled, automatic insufﬂ

A lar

e pocket of

as is produced in the

reater peritoneal sac, enablin

sur

cal instruments to be advanced without dama

the viscera and vascular

tructures

[

]

https://t.me/med1917

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