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Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

Published:December 26, 2020DOI:https://doi.org/10.1016/j.jogc.2020.12.012

      ABSTRACT

      Objective

      To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

      Target population

      All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

      Options

      The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle–pneumoperitoneum–trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

      Outcomes

      Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

      Evidence

      We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

      Validation methods

      The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

      Intended audience

      Surgeons performing laparoscopic gynaecological surgery.

      SUMMARY STATEMENTS

      • 1
        Laparoscopic entry using the Veress needle–pneumoperitoneum–trocar (or “closed”) technique is practised by the majority of gynaecologists worldwide (I).
      • 2
        During closed entry, caudal umbilical displacement below the sacrum and great vessels facilitates intraperitoneal placement of the Veress needle and maximizes the success of entry and avoidance of injury (I).
      • 3
        The Veress needle can be inserted intraperitoneally at umbilical or left upper quadrant sites. Left upper quadrant placement is associated with fewer attempts and fewer conversions to alternative sites (I).
      • 4
        Initial Veress intraperitoneal pressure of <10 mm Hg is the most reliable indicator of correct Veress needle placement (I).
      • 5
        Shielded trocars do not result in fewer visceral or vascular injuries during laparoscopic access (II-2).
      • 6
        The blunt tip of the radially expanding trocars may provide protection from injuries, but the force required for entry is significantly greater than for disposable trocars (I).
      • 7
        Single-use, push-through, optical trocars are not superior to blind methods of inserting trocars and do not avoid visceral or vascular injury (II-2).
      • 8
        Reusable visual entry cannulas have no sharp or pointed trocar, minimize port wound size, and reduce insertional force; as a consequence, they may be safer than trocars (II-2).
      • 9
        Direct trocar insertion is associated with fewer insufflation complications and failed entries. However, there is insufficient evidence to conclude that direct insertion is associated with fewer major complications (I).
      • 10
        Open entry is neither superior nor inferior to other entry techniques. Open entry has a lower incidence of vascular injuries but a potentially higher incidence of bowel injury (I).
      • 11
        Laparoscopy can be performed in pregnancy (II-2).

      RECOMMENDATIONS

      • 1
        Alternative insertion sites for the Veress needle (e.g., left upper quadrant [Palmer's point], transvaginal, or transuterine) should be considered (1) when an umbilical entry is considered complicated, based on patient history and characteristics (e.g., suspected or known periumbilical adhesions, history or presence of umbilical hernia, low or high body mass index) or (2) after 3 failed attempts at umbilical Veress needle insertion (I-A).
      • 2
        Elevation of the abdominal wall during insertion of a Veress needle or primary trocar is not routinely recommended because it does not avoid visceral or vessel injury (II-2E).
      • 3
        Because the position of the umbilicus in relation to the aortic bifurcation varies according to the patient's body mass index, the angle of insertion of the Veress needle at the umbilicus should be adjusted accordingly—from 45° in women of normal body mass to 90° in women with obesity (I-A).
      • 4
        Previously recommended Veress needle safety checks or tests, such as the saline drop test and aspiration for fluid, have not been found to confirm position and therefore are no longer recommended as best practice (I-A).
      • 5
        Wiggling the Veress needle from side to side should be avoided; this can increase the risk of complications (II-1E).
      • 6
        It is appropriate to to leave the source of gas attached to the Veress needle so that the surgeon can use the pressure gauge to measure the intraperitoneal pressure (<10 mm Hg) as the most reliable indicator of correct placement of the Veress needle (I-A).
      • 7
        The volume of CO2 insufflated with the Veress needle before trocar insertion should depend on intra-abdominal pressure. Adequate pneumoperitoneum insufflation should be determined by a pressure of 20–30 mm Hg rather than by CO2 volume (II-1 A).
      • 8
        During entry using Veress needle insufflation, intraperitoneal pressure may be increased immediately before insertion of the trocars. Transiently high intraperitoneal pressure does not adversely affect cardiopulmonary function in healthy patients (II-1 A).
      • 9
        The threaded, reusable, visual cannula may be considered a safer instrument for peritoneal entry than conventional trocars (II-2 B).
      • 10
        Direct trocar insertion may be used in accordance with the surgeon's training, experience, and preference (I B).
      • 11
        Open (Hasson) entry may be used in accordance with the surgeon's training, experience, and preference (II-2 C).
      • 12
        Because there is no clear consensus on the optimal method of peritoneal entry, surgeons should use the technique with which they are most comfortable and experienced (II-2 C).
      • 13
        In women requiring intra-abdominal surgery in pregnancy, Veress needle insufflation at the umbilical site can be employed until 14 weeks gestation (if there are no contraindications), and open (Hasson) entry or left upper quadrant insufflation are preferable after 14 weeks gestation (II-2 B). After 24 weeks gestation, an open (Hasson) entry is recommended (II-2 B).

      Keywords

      ABBREVIATIONS:

      DTI (Direct trocar insertion), LUQ (Left upper quadrant), VIP (Veress intraperitoneal pressure)
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