Laparoscopy

Question 1

What tests are available to check for correct placement of the Veress needle?

Answer 1

• Direct intraperitoneal pressures measurement: immediate gas pressures on entry and 5 successive pressures <8mmHg. Highest sensitivity and specificity.
• Aspiration test: attach a syringe filled with saline to open end of Veress needle and aspirating. Remove if bowel contents or urine aspirated; leave in place and prep for laparotomy if blood aspirated. If no material aspirated, 5mL of saline is inserted and reattempt to aspirate. If not fluid is aspirated, entry into peritoneal cavity is confirmed. If saline is aspirated, and enclosed space was probably entered and needle should be repositioned.
• Hanging/saline drop test: place a drop of saline on open end of Veress needle and lifting the abdominal wall; if needle is correctly positioned, water should disappear down shaft.

Question 2

Which artery is most commonly at risk of damage during the placement of a low lateral secondary port?

Briefly describe the anatomy of this artery and the practical steps that can be taken to avoid injury to this vessel.

Answer 2

Inferior epigastric artery.

Arises from external iliac artery. Runs superiorly from inguinal ligament in transversalis fascia and enters rectus sheath below arcuate line and enters lower rectus abdominis running deep to this.

Visualise medial umbilical ligament prior to port placement; inferior epigastric artery runs immediately lateral to this. Avoid port placement in this area.

Question 3

How common is the risk of serious complications in laparoscopy?

Answer 3

1 in 1000

Question 4

What factors increase the risk of complications in laparoscopic surgery?

Answer 4

Overweight.
Underweight.
Previous midline abdo incisions.
Previous peritonitis or inflammatory bowel disease.

Question 5

What are the indications for Palmer’s point entry?

Answer 5

Previous surgery at umbilicus.

Splenomegaly.

Question 6

Describe the anatomical location of Palmer’s point

Answer 6

In LUQ, 3 cm below the left costal edge in the midclavicular line.

Question 7

What structure should you identify when inserting secondary ports?

Describe the anatomical landmarks used to identify this.

Answer 7

Inferior epigastric vessels.

Lie just lateral to the medial umbilical ligament.

Question 8

What patient characteristics increase the risk of vascular injury during laparoscopic entry?

Answer 8

Young.
Slim.
Nulliparous.
Well developed abdominal musculature. 
Aorta may be less than 2.5 cm below the skin.