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.
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