How is laparoscopy initiated?
The most frequent surgical complications are associated with the creation of the initial pneumoperitoneum. Being familiar with the surgical technique enables one to better anticipate these untoward events.
Carbon dioxide (CO2) is insufflated through a Veress needle, which is blindly inserted just beneath the umbilicus into the peritoneal cavity. Confirmation of intraperitoneal placement of the Veress needle may be done in several ways. Firstly, the “pop” of piercing fascia and peritoneum may be appreciated. This is the most “unscientific” of the approaches, yet probably the most common method used. Secondly, a drop of water may be left on the hub of the Veress needle. As the peritoneum is entered, the negative pressure that exists within the cavity will “suck in” the drop. This is said to be the safest of the methods described. Lastly, after insertion of the Veress needle, on initial insuf-flation, the intraperitoneal pressures should not be greater than 8–9 mmHg. Once insufflation begins, percussion of air in the abdomen is a promising sign. An abrupt, very high increase in abdominal pressure with the onset of gas flow may signify extraperitoneal insufflation. A “Hassan” mini-laparotomy technique has been advocated for pneu-moperitoneum creation to avoid the injuries associated with the blind Veress needle insertion. An electronic variable-flow insufflator terminates flow when a preset intra-abdomi-nal pressure of 12–15 mmHg has been reached. A cannula, or trocar, is then inserted in place of the needle. A video laparo-scope is inserted through the cannula, and the operative field is visualized via the camera and monitoring systems.