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Modified open laparoscopy through placement of an optical surgical obturator
Techniques and instrumentation Vol. 67. No. 5, May 1997
FERTILITY AND STERILITY@ Copyright ” 1997 American Society for Reproductive Medicine Pubbshed by Elsevier Science Inc.
Modified open laparoscopy through placement of an optical surgical obturator
Steven G. Kaali, M.D.* David H. Barad, M.D. Irwin R. Merkatz, M.D. Albert Einstein College of Medicine, Bronx, New York
Objective: To describe a new technique for open laparoscopy. Design: Prospective case series. Setting: Ambulatory surgical unit. Patient(s): Fifty-six women undergoing laparoscopic sterilization. Intervention(s): Intra-abdominal placement of an optical surgical obturator. Main Outcome Measure(s): Evaluation of surgical technique. Result(s): The technique was completed successfully in all cases. Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent (Fertil Steril@ 1997;67:969-71. 0 1997 by American Society for Reproductive injuries. Medicine.) Key Words: Open laparoscopy,
modified, Endopath
Traumatic complications during blind insertion of the laparoscopic trocar occur despite adequate surgical experience and up-to-date equipment (1). Open laparoscopy has been advocated to reduce inadvertent injuries during abdominal entry (2) but serious complications also have been reported with this technique (3). In this report, we describe a new and potentially safer approach to open laparoscopy. MATERIALS
Optiview
out under general anesthesia. The patients’ weight ranged from 116 to 204 lb (53 to 93 kg) Twenty-one women had undergone previous laparotomies. A 1.5cm transverse superficial skin incision was
AND METHODS
We have initiated the use of modified open technique for all patients undergoing laparoscopic procedures starting on May 1, 1996. The first 56 consecutive women who consented to elective laparoscopic sterilization are represented in this series. All subjects were healthy, and the procedures were carried
Received October 24, 1996; revised and accepted January 22, 1997. * Reprint requests: Steven G. Kaali, M.D., 88 Ashford Avenue, Dobbs Ferry, NY 10522 (FAX: 914-693-0651).
00150282/97/$17.00 PI1 s0015-0282(97)00129-5
Figure 1 Optical surgical obturator with its removable sheath (Endopath Optiview Instrument; Ethicon Endo-Surgery Inc.).
969
a continuous video-derived image (Figs. 1 and 2). The assembly was passed through the fascial opening, and an area of transparent peritoneum with underlying abdominal organs was recognized visually. The instrument then was guided into the abdominal cavity (Fig. 3). RESULTS
Figure 2 Endopath Optiview complemented scope and light and video attachments.
by a 0” l.O-cm tele-
made at the lower rim of the umbilicus. The subcutaneous fatty connective tissue was dissected bluntly by a small Kelly clamp (Miltex Surgical Instruments, Lake Success, NY) until the resistance of the fascia was felt. Two Crile retractors (Miltex Surgical Instruments) were placed in the incision, and the white surface of the fascia was identified visually. The fully exposed fascia was penetrated bluntly and split vertically along its longitudinal fibers with a straight tissue hemostat, and the fascial opening was enlarged to 1.0 cm. The standard light telescope was placed into the Endopath Optiview Instrument (Ethicon Endo-Surgery, Cincinnati, OH) to provide
The technique was completed successfully in all cases. In one patient who had undergone three previous cesarean sections, omental adhesions were recognized visually before intraperitoneal penetration was initiated. The instrument was redirected to identify an area of safe passage into the abdominal cavity. DISCUSSION
Physicians familiar with conventional open laparoscopy are aware that complications are most likely to occur at the point of peritoneal entry because of greatly reduced visibility at the base of the typically small incision. Even the most experienced surgeon can have difficulty recognizing bowel or omental adhesions through a l.O-cm fascial opening using the conventional operative technique. The standard light telescope complemented by the Endopath Optiview provides sufficient illumination and direct visualization during the entire penetration process even through such a small opening. Endopath Optiview
Figure 3 Direct view observed through the telescope before imminent intraperitoneal entry. White fascia (A), vascular preperitoneal fat (B), transparent peritoneum (0, and plastic tissue separators (D).
970
Kaali et al.
Techniques and instrumentation
Fertility and Sterility@
Figure 4 Protruding semilunar blade in the tip of Visiport (Zefi); blunt conical tip of Endopath Optiview with recessed plastic tissue separators (right).
has an optically clear blunt conical tip with recessed tissue separators on each side to safeguard against tissue damage on contact (4). To our knowledge there is only one other instrument (Visiport; US Surgical, Norwalk, CT) that incorporates a light telescope during the entry process. The main difference between these two instruments is that the Visiport has a semilunar blade controlled by a trigger mechanism in front of the viewing area. Once the surgeon pulls the trigger, the cutting action by the blade no longer is controlled visually. Sharp blind cutting remains a prerequisite for advancing the Visiport. In contrast, the Endopath Optiview allows controlled blunt separation of tissues under continuous direct visualization (Fig. 4). The advantage of creating a fascial opening ~1.0 cm is that this small opening helps to accommodate firmly the optical obturator. This permits adequate stability for the sheath of the instrument within the abdominal wall, helps to maintain pneumoperito-
Vol. 67, No. 5, May 1997
neum, and eliminates the need for special open laparoscopy instruments. It should be stressed that the operator needs to become familiar with a new contact view of tissues being separated. This is different from the conventional intracavitary image with which most physicians are familiar. We estimate that the learning curve lasts about 10 patients. Once the surgeon is comfortable recognizing the various tissues on contact, he or she develops a sense of security regarding the location of the tip of the penetrating instrument at any given moment. In this small series, only one patient exhibited omental adhesions at the anticipated entry site. The obstacle was visually recognized immediately, and a larger peritoneal surface then was evaluated for safe intraperitoneal insertion of the telescope. Video documentation of this critical step is an important teaching tool and in the longer run may provide important medicolegal protection. Our initial clinical observations suggest that by avoiding sharp instruments altogether during the insertion process and by maintaining continuous visual control throughout the intraperitoneal entry, the surgeon becomes confident in the overall safety of this commonly used procedure. REFERENCES Yuzpe AA. Pneumoperitoneum needle and trocar injuries in laparoscopy. A survey on possible contributing factors and prevention. J Reprod Med 1990;35:485-90. Hasson HH. Open laparoscopy. In: Sciarra JJ, editor. Gynecology and obstetrics. Vol. 6. New York: Harper & Row, 1984. Sageghi-Nejad H, Kavuossi LR, Peters CA. Bowel injury in open technique laparoscopic cannula placement. Urology 1994;43:559-60. Kaali SG, Barad DH, Merkatz IR. Visually guided trocar entry: experience with the Endopath Optiview. In: Szabo Z, Fantini A, Lewis JE, Savalgl RS, editors. Surgical Technology International. Vol. 5. San Francisco: Universal Medical Press Inc., 1996:153-6.
Kaali et al.
Techniques
and instrumentation
971
FERTILITY AND STERILITY@ Copyright ” 1997 American Society for Reproductive Medicine Pubbshed by Elsevier Science Inc.
Modified open laparoscopy through placement of an optical surgical obturator
Steven G. Kaali, M.D.* David H. Barad, M.D. Irwin R. Merkatz, M.D. Albert Einstein College of Medicine, Bronx, New York
Objective: To describe a new technique for open laparoscopy. Design: Prospective case series. Setting: Ambulatory surgical unit. Patient(s): Fifty-six women undergoing laparoscopic sterilization. Intervention(s): Intra-abdominal placement of an optical surgical obturator. Main Outcome Measure(s): Evaluation of surgical technique. Result(s): The technique was completed successfully in all cases. Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent (Fertil Steril@ 1997;67:969-71. 0 1997 by American Society for Reproductive injuries. Medicine.) Key Words: Open laparoscopy,
modified, Endopath
Traumatic complications during blind insertion of the laparoscopic trocar occur despite adequate surgical experience and up-to-date equipment (1). Open laparoscopy has been advocated to reduce inadvertent injuries during abdominal entry (2) but serious complications also have been reported with this technique (3). In this report, we describe a new and potentially safer approach to open laparoscopy. MATERIALS
Optiview
out under general anesthesia. The patients’ weight ranged from 116 to 204 lb (53 to 93 kg) Twenty-one women had undergone previous laparotomies. A 1.5cm transverse superficial skin incision was
AND METHODS
We have initiated the use of modified open technique for all patients undergoing laparoscopic procedures starting on May 1, 1996. The first 56 consecutive women who consented to elective laparoscopic sterilization are represented in this series. All subjects were healthy, and the procedures were carried
Received October 24, 1996; revised and accepted January 22, 1997. * Reprint requests: Steven G. Kaali, M.D., 88 Ashford Avenue, Dobbs Ferry, NY 10522 (FAX: 914-693-0651).
00150282/97/$17.00 PI1 s0015-0282(97)00129-5
Figure 1 Optical surgical obturator with its removable sheath (Endopath Optiview Instrument; Ethicon Endo-Surgery Inc.).
969
a continuous video-derived image (Figs. 1 and 2). The assembly was passed through the fascial opening, and an area of transparent peritoneum with underlying abdominal organs was recognized visually. The instrument then was guided into the abdominal cavity (Fig. 3). RESULTS
Figure 2 Endopath Optiview complemented scope and light and video attachments.
by a 0” l.O-cm tele-
made at the lower rim of the umbilicus. The subcutaneous fatty connective tissue was dissected bluntly by a small Kelly clamp (Miltex Surgical Instruments, Lake Success, NY) until the resistance of the fascia was felt. Two Crile retractors (Miltex Surgical Instruments) were placed in the incision, and the white surface of the fascia was identified visually. The fully exposed fascia was penetrated bluntly and split vertically along its longitudinal fibers with a straight tissue hemostat, and the fascial opening was enlarged to 1.0 cm. The standard light telescope was placed into the Endopath Optiview Instrument (Ethicon Endo-Surgery, Cincinnati, OH) to provide
The technique was completed successfully in all cases. In one patient who had undergone three previous cesarean sections, omental adhesions were recognized visually before intraperitoneal penetration was initiated. The instrument was redirected to identify an area of safe passage into the abdominal cavity. DISCUSSION
Physicians familiar with conventional open laparoscopy are aware that complications are most likely to occur at the point of peritoneal entry because of greatly reduced visibility at the base of the typically small incision. Even the most experienced surgeon can have difficulty recognizing bowel or omental adhesions through a l.O-cm fascial opening using the conventional operative technique. The standard light telescope complemented by the Endopath Optiview provides sufficient illumination and direct visualization during the entire penetration process even through such a small opening. Endopath Optiview
Figure 3 Direct view observed through the telescope before imminent intraperitoneal entry. White fascia (A), vascular preperitoneal fat (B), transparent peritoneum (0, and plastic tissue separators (D).
970
Kaali et al.
Techniques and instrumentation
Fertility and Sterility@
Figure 4 Protruding semilunar blade in the tip of Visiport (Zefi); blunt conical tip of Endopath Optiview with recessed plastic tissue separators (right).
has an optically clear blunt conical tip with recessed tissue separators on each side to safeguard against tissue damage on contact (4). To our knowledge there is only one other instrument (Visiport; US Surgical, Norwalk, CT) that incorporates a light telescope during the entry process. The main difference between these two instruments is that the Visiport has a semilunar blade controlled by a trigger mechanism in front of the viewing area. Once the surgeon pulls the trigger, the cutting action by the blade no longer is controlled visually. Sharp blind cutting remains a prerequisite for advancing the Visiport. In contrast, the Endopath Optiview allows controlled blunt separation of tissues under continuous direct visualization (Fig. 4). The advantage of creating a fascial opening ~1.0 cm is that this small opening helps to accommodate firmly the optical obturator. This permits adequate stability for the sheath of the instrument within the abdominal wall, helps to maintain pneumoperito-
Vol. 67, No. 5, May 1997
neum, and eliminates the need for special open laparoscopy instruments. It should be stressed that the operator needs to become familiar with a new contact view of tissues being separated. This is different from the conventional intracavitary image with which most physicians are familiar. We estimate that the learning curve lasts about 10 patients. Once the surgeon is comfortable recognizing the various tissues on contact, he or she develops a sense of security regarding the location of the tip of the penetrating instrument at any given moment. In this small series, only one patient exhibited omental adhesions at the anticipated entry site. The obstacle was visually recognized immediately, and a larger peritoneal surface then was evaluated for safe intraperitoneal insertion of the telescope. Video documentation of this critical step is an important teaching tool and in the longer run may provide important medicolegal protection. Our initial clinical observations suggest that by avoiding sharp instruments altogether during the insertion process and by maintaining continuous visual control throughout the intraperitoneal entry, the surgeon becomes confident in the overall safety of this commonly used procedure. REFERENCES Yuzpe AA. Pneumoperitoneum needle and trocar injuries in laparoscopy. A survey on possible contributing factors and prevention. J Reprod Med 1990;35:485-90. Hasson HH. Open laparoscopy. In: Sciarra JJ, editor. Gynecology and obstetrics. Vol. 6. New York: Harper & Row, 1984. Sageghi-Nejad H, Kavuossi LR, Peters CA. Bowel injury in open technique laparoscopic cannula placement. Urology 1994;43:559-60. Kaali SG, Barad DH, Merkatz IR. Visually guided trocar entry: experience with the Endopath Optiview. In: Szabo Z, Fantini A, Lewis JE, Savalgl RS, editors. Surgical Technology International. Vol. 5. San Francisco: Universal Medical Press Inc., 1996:153-6.
Kaali et al.
Techniques
and instrumentation
971