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LapCap: A Novel Device to Reduce Entry Complications
Accepted Manuscript Title: Lapcap : a Novel Device to Reduce the Entry Complications Author: Ramesh Bettaiah, Shwetha Sudhakar Kamath, Rachana Ghanti PII: DOI: Reference:
S1553-4650(17)31086-5 http://dx.doi.org/doi: 10.1016/j.jmig.2017.08.644 JMIG 3247
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
29-7-2017 4-8-2017 9-8-2017
Please cite this article as: Ramesh Bettaiah, Shwetha Sudhakar Kamath, Rachana Ghanti, Lapcap : a Novel Device to Reduce the Entry Complications, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.08.644. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
LAPCAP : A NOVEL DEVICE TO REDUCE THE ENTRY COMPLICATIONS
Ramesh Bettaiah, DGO,MD,FCPS,DFP,FICOG, Shwetha Sudhakar Kamath, MS. Rachana Ghanti, MS Department Of Obstetrics And Gynaecology, Advanced Laparoscopy Division, Altius Hospital, Bangalore, India. CORRESPONDING AUTHOR: DR SHWETHA S KAMATH [email protected] mail address:# 129, akshaya, 4th main road, ganganagar , bangalore , karnataka, india- 560032 or # 6/63, 59th cross, 4th block, rajajinagar, opp MEI polytecnic, near ram mandir, bangalore, karnataka-560010. This is to declare that I have no personal or financial interests to declare I have no financial support from an industry source at the current presentation there is no conflict of interest
Abstract: Laparoscopy is one of the most common procedures performed worldwide .Over 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase. Major vascular injury during the initiation of a pneumoperitoneum is a much feared complication of laparoscopic procedures.This can be overcome by using a vacuum cup at the time of Veress entry especially in thin patients.The vacuum cup is a simple device to create pneumoperitoneum with ease . It can significantly reduce the risk of retroperitoneal injury associated with the use of Veress needle. It can be of great help to beginners in laparoscopy. Keywords: veress , laparoscopy, entry complications, LapCap
Page 1 of 3
Laparoscopy is one of the most common procedures performed worldwide .Over 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase. There is no clear advantage of one method over other , from the available modalities for abdominal entry. However Veress entry is the most popular method among gynecologists. Major vascular injury during the initiation of a pneumoperitoneum is a much feared complication of laparoscopic procedures, with a reported mortality rate of 15%. This is because of the close proximity of the anterior abdominal wall to the retroperitoneal vascular structures, which in thin patients can be as little as two centimeters. This can be overcome by using a LapCap(Aragon Surgical, Inc) (Fig 1) at the time of Veress entry in thin patients. It was originally described by Nezhat as early as 2007 .The device is placed over the abdominal wall, with umbilicus at its centre (Fig 2 A). The suction is attached (Fig 2 B). This elevates the abdominal wall into the dome, creating a cone-shaped vacuum space of peritoneal cavity within the vacuum cup dome (Fig 2 C). The suction should be applied three times prior to insertion of the Veress needle in order to displace the omentum and bowel from the anterior abdominal wall. The Veress is safely pierced through the umbilicus and pneumoperitoneum created (Fig 2 D).The pressure reading at entry can be almost double the actual intra-abdominal pressure because of the smaller volume of the abdominal cavity within the vacuum cup. Once the pressure reaches 20mm, vacuum is released (Fig 3 A). Subsequently, the intra abdominal pressure may fall. The Veress remains in place and insufflation can be continued till desired pressure is achieved (Fig 3B).The vacuum cup with Veress is then removed (Fig 3 C). Subsequently the trocar is placed (Fig 3 D). Charles R performed a prospective trial to evaluate the safety of the device. In all 48 patients, the Veress needle was correctly placed using the LapCap on the first attempt with no complications. The skin was also evaluated and demonstrated no trauma from the device.We have used the device in over 15 patients over the last 6 months. The entry was successful, easy and without any complications in all th cases.though initially there was a doubt about the intraperitoneal location of the veress. One disadvantage of this device is the small area in the cone can cause an artificially high pressure reading. Pressure reading of up to 20mmHg may be seen even with correct intraperitoneal placement, and is usually double the actual intraperitoneal pressure. After release of the vacuum, the pressure reading will decrease by approximately 50%. Surgeons will have to use other methods such as the saline drop test to confirm intraperitoneal placement. After 2-3 cases the use of Lapcap becomes very comfortable. In patients with prior surgeries, adhesions to the abdominal wall at the umbilicus would still be a concern. Some centres use the mapping technique particularly in patients with prior surgeries after insufflation of the abdomen and prior to primary trocar placement. At our centre, this device is placed at a site away from the umbilicus, most commontly the Palmer’s point. Another difference with this device is that no skin incision is made prior to insertion of the Veress needle. If a skin incision is made, the negative pressure from the vacuum increases bleeding from the skin incision site. Thus, the surgeon should anticipate three "clicks" prior to intraperitoneal placement (skin, fascia, peritoneum) as opposed to the usual two. The LapCap is a simple device to create pneumoperitoneum with ease especially in thin patients. However ,this device can also be
Page 2 of 3
applied to obese patients. It is important to remember in these patients that the full length of a 15cm Veress needle may need to be inserted, normally <5cm is inserted. It can significantly reduce the risk of retroperitoneal injury associated with the use of Veress needle. This is also a useful device to decrease the number of attempts with abdominal entry. This is important as the risk of bowel and vessel injury increases with the number of attempts at entry. This may especially be helpful in teaching residents who are first starting to learn abdominal entry techniques, as well as others who are not as proficient in laparoscopic surgery
There is no conflict of interest Reference 1. Nezhat C, Nezhat C, Nezhat F, Ferland R, Lewis M, King LP. Laparoscopic Access. http://laparoscopy.blogs.com/prevention_management_3/2011/04/laparoscopic-access.html
INSTITUTIONAL REVIEW BOARD/ ETHICS COMMITTEE APPROVAL WAS OBTAINED
Figure 1. LAPCAP Figure 2. A. THIN PATIENT WITH FLAT ABDOMEN B. DEVICE PLACED OVER ABDOMEN C. SUCTION CONNECTED AND VACUUM CREATED D. VERESS INSERTED AND PNEUMOPERITONEUM CREATED Figure 3. A. VACUUM RELESED B. VERESS IN PLACE AND INSUFFLATION CONTINUED C. LAPCAP WITH VERESS REMOVED D. TROCAR INSERTED
Page 3 of 3
S1553-4650(17)31086-5 http://dx.doi.org/doi: 10.1016/j.jmig.2017.08.644 JMIG 3247
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
29-7-2017 4-8-2017 9-8-2017
Please cite this article as: Ramesh Bettaiah, Shwetha Sudhakar Kamath, Rachana Ghanti, Lapcap : a Novel Device to Reduce the Entry Complications, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.08.644. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
LAPCAP : A NOVEL DEVICE TO REDUCE THE ENTRY COMPLICATIONS
Ramesh Bettaiah, DGO,MD,FCPS,DFP,FICOG, Shwetha Sudhakar Kamath, MS. Rachana Ghanti, MS Department Of Obstetrics And Gynaecology, Advanced Laparoscopy Division, Altius Hospital, Bangalore, India. CORRESPONDING AUTHOR: DR SHWETHA S KAMATH [email protected] mail address:# 129, akshaya, 4th main road, ganganagar , bangalore , karnataka, india- 560032 or # 6/63, 59th cross, 4th block, rajajinagar, opp MEI polytecnic, near ram mandir, bangalore, karnataka-560010. This is to declare that I have no personal or financial interests to declare I have no financial support from an industry source at the current presentation there is no conflict of interest
Abstract: Laparoscopy is one of the most common procedures performed worldwide .Over 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase. Major vascular injury during the initiation of a pneumoperitoneum is a much feared complication of laparoscopic procedures.This can be overcome by using a vacuum cup at the time of Veress entry especially in thin patients.The vacuum cup is a simple device to create pneumoperitoneum with ease . It can significantly reduce the risk of retroperitoneal injury associated with the use of Veress needle. It can be of great help to beginners in laparoscopy. Keywords: veress , laparoscopy, entry complications, LapCap
Page 1 of 3
Laparoscopy is one of the most common procedures performed worldwide .Over 50% of laparoscopic injuries to the gastrointestinal tract and major vessels occur during the initial entry phase. There is no clear advantage of one method over other , from the available modalities for abdominal entry. However Veress entry is the most popular method among gynecologists. Major vascular injury during the initiation of a pneumoperitoneum is a much feared complication of laparoscopic procedures, with a reported mortality rate of 15%. This is because of the close proximity of the anterior abdominal wall to the retroperitoneal vascular structures, which in thin patients can be as little as two centimeters. This can be overcome by using a LapCap(Aragon Surgical, Inc) (Fig 1) at the time of Veress entry in thin patients. It was originally described by Nezhat as early as 2007 .The device is placed over the abdominal wall, with umbilicus at its centre (Fig 2 A). The suction is attached (Fig 2 B). This elevates the abdominal wall into the dome, creating a cone-shaped vacuum space of peritoneal cavity within the vacuum cup dome (Fig 2 C). The suction should be applied three times prior to insertion of the Veress needle in order to displace the omentum and bowel from the anterior abdominal wall. The Veress is safely pierced through the umbilicus and pneumoperitoneum created (Fig 2 D).The pressure reading at entry can be almost double the actual intra-abdominal pressure because of the smaller volume of the abdominal cavity within the vacuum cup. Once the pressure reaches 20mm, vacuum is released (Fig 3 A). Subsequently, the intra abdominal pressure may fall. The Veress remains in place and insufflation can be continued till desired pressure is achieved (Fig 3B).The vacuum cup with Veress is then removed (Fig 3 C). Subsequently the trocar is placed (Fig 3 D). Charles R performed a prospective trial to evaluate the safety of the device. In all 48 patients, the Veress needle was correctly placed using the LapCap on the first attempt with no complications. The skin was also evaluated and demonstrated no trauma from the device.We have used the device in over 15 patients over the last 6 months. The entry was successful, easy and without any complications in all th cases.though initially there was a doubt about the intraperitoneal location of the veress. One disadvantage of this device is the small area in the cone can cause an artificially high pressure reading. Pressure reading of up to 20mmHg may be seen even with correct intraperitoneal placement, and is usually double the actual intraperitoneal pressure. After release of the vacuum, the pressure reading will decrease by approximately 50%. Surgeons will have to use other methods such as the saline drop test to confirm intraperitoneal placement. After 2-3 cases the use of Lapcap becomes very comfortable. In patients with prior surgeries, adhesions to the abdominal wall at the umbilicus would still be a concern. Some centres use the mapping technique particularly in patients with prior surgeries after insufflation of the abdomen and prior to primary trocar placement. At our centre, this device is placed at a site away from the umbilicus, most commontly the Palmer’s point. Another difference with this device is that no skin incision is made prior to insertion of the Veress needle. If a skin incision is made, the negative pressure from the vacuum increases bleeding from the skin incision site. Thus, the surgeon should anticipate three "clicks" prior to intraperitoneal placement (skin, fascia, peritoneum) as opposed to the usual two. The LapCap is a simple device to create pneumoperitoneum with ease especially in thin patients. However ,this device can also be
Page 2 of 3
applied to obese patients. It is important to remember in these patients that the full length of a 15cm Veress needle may need to be inserted, normally <5cm is inserted. It can significantly reduce the risk of retroperitoneal injury associated with the use of Veress needle. This is also a useful device to decrease the number of attempts with abdominal entry. This is important as the risk of bowel and vessel injury increases with the number of attempts at entry. This may especially be helpful in teaching residents who are first starting to learn abdominal entry techniques, as well as others who are not as proficient in laparoscopic surgery
There is no conflict of interest Reference 1. Nezhat C, Nezhat C, Nezhat F, Ferland R, Lewis M, King LP. Laparoscopic Access. http://laparoscopy.blogs.com/prevention_management_3/2011/04/laparoscopic-access.html
INSTITUTIONAL REVIEW BOARD/ ETHICS COMMITTEE APPROVAL WAS OBTAINED
Figure 1. LAPCAP Figure 2. A. THIN PATIENT WITH FLAT ABDOMEN B. DEVICE PLACED OVER ABDOMEN C. SUCTION CONNECTED AND VACUUM CREATED D. VERESS INSERTED AND PNEUMOPERITONEUM CREATED Figure 3. A. VACUUM RELESED B. VERESS IN PLACE AND INSUFFLATION CONTINUED C. LAPCAP WITH VERESS REMOVED D. TROCAR INSERTED
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