Logan Rawlins, MD, Peter Hallowell, MD, Bruce Schirmer, MD
University of Virginia
Objective: Many access techniques for laparoscopic surgery have been described including fascial cut-down, direct optical trocar entry, and Veress needle pre-insufflation. No entry technique has clearly shown to be superior, though some surgeons shy away from the Veress needle given the concern for intra-abdominal injury with blind placement of a spring loaded needle. To overcome this concern, elevating the skin with towel clips has been employed in an attempt to lift the abdominal wall away from structures below the peritoneum. This is often troublesome and ineffective in patients with obesity and skin laxity. We have used a different method which improves this technique a step further while still maintaining the most minimally invasive access technique possible.
Description of Technique/Results: Our novel addition to Veress needle insufflation includes the use of a tracheostomy hook to help elevate the fascia. We use this in both the periumbilical and left upper quadrant locations preferably, but have also used it in the right upper quadrant. After a small skin incision is made, the tracheostomy hook is tunneled through the subcutaneous tissue till it grabs the fascia beneath. Direct elevation of the fascia, not just the skin, with associated counter tension affords the possibility of a safer entry technique. In over eleven years (approximately 400 laparoscopic cases per year) of performing this technique, we have not experienced a vascular or bowel injury, and rarely if ever have to convert to another technique.
Conclusion: Veress needle pre-insufflation of the abdomen assisted by a tracheostomy hook can be utilized by the laparoscopic surgeon for better ease of placement and direct elevation of the abdominal wall.
Session: Poster Presentation
Program Number: P488