Lap chole after previous lap - Forum

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Poland

Lap chole after previous lap - Ärzteforum

Post#1 »

I have been doing lap choles for a the past 3 years, but never did one after previous lap. I need to do one now on a pt. who has a midline scar from xiphi to pubis done for small bowel resection. I need advise about approach to port placement. Where would you place first port. Can it be done closed or must it be done as a open proceedure etc.etc..The concern is not to injure bowel on entering the abdomen.


Jorjo

Re: Lap chole after previous lap - Ärzteforum

Post#2 »

You need to access the abdomen through a very small umbilical incision (Hassan'technique) opened,so as to see the site to enter and place your trocar N=B0 1 under direct vision so as to not damage any viscerae that could be fixed near the area. Then,insufflate slowly watching that expansion of abdomen is equal and regular.Then,when the optic device is introduced you will see a real cavern with adhesions lifted upside and you will know if dissection of such adherences is feasible.If you think they are,you start liberating them but previously you introduce the other 3 trocars under direct vision.If things appear to be rather difficult we would advice you to convert your surgery to open type and carry on with a classical operation.

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Lady Surgeon

Re: Lap chole after previous lap - Ärzteforum

Post#3 »

Let me offer an alternative viewpoint. In over 800 laparoscopic cases, I have felt the need to use the Hassan technique in only three, and all were in various stages of pregnancy at the time. I have always used the Veress needle exclusively. My bowel injury rate is zero. I have had to convert lap chole's for the usual technical reasons (difficulties, not complications), have had to open two cases because the sheer density of adhesions prevented development of an adequate space, but have not had to open for access.

Tips:

1) a sharp needle. Some of the re-re-resharpened ones just aren't as effective. Not a slight against reusables - I use them - but quality is an issue.

2) avoid the problem area - the midline. During a laparotomy, one avoids adhesions in entering the abdomen in order to avoid injury. Why relearn the lesson laparoscopically? Insert your needle at the site for the midclavicular port. Or further laterally. Lift up the midline, and direct the needle perpendicular to the wall. The sensatiion is not quite as "crisp" when inserting the needle, but is nevertheless distinct.

3) If you have to use the Hassan, avoid the midline. Nothing like reading the reports of "how we used the Hassan to avoid injury" - then went through the midline, and into the transverse colon anyway. Why look for trouble (adhesions)? Stay away.

Not scientific, perhaps, but certainly effective. My three partners' experiences mirror mine. None of us have any experience with the Hassan. One has used the dagger-like trigger assembly which the camera slides down, from US Surgical. He claims success, but it seems like you would just see yourself entering the colon up close and personal, rather than avoid the bad stuff.

सर्जन

Re: Lap chole after previous lap - Ärzteforum

Post#4 »

The best approaches are the minimal risk not the minimal invasive.The only sure way is to do an open cholecystectomy. if you are still vain place port only by open insertion under direct vision away from midline. if adhesions ++ then back to the start do open chole !

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Doctor Green

Re: Lap chole after previous lap - Ärzteforum

Post#5 »

If you are using the open method of establishing your pneumoperitoneum, then you may be well able to safely enter the abdomen through the umbilicus or close to it. I often do lap work in abdomens with scars. We often encounter adhesions which make me glad that I was encouraged very early on to use the Hasson blunt cannula and to avoid the Veress needle. I think you have to proceed very carefully, but can put the cannula anywhere (say at lateral edge of rectus at umbilical level) and look around. Often after placing a second port in a convenient place the adhesions can be cleared and the umbilicus can then be used as usual.

John Dissector

Re: Lap chole after previous lap - Ärzteforum

Post#6 »

I do all my initial umbilical port placements open, every case, so would advise this. Some people I know start to one side or the other in cases of previous laparotomy (or in the upper abdomen). I use the Hasson S retractors (the whole trick to the open approach--there is no other good way to expose the fascia, especially in the obese (did 325 and 370 female lap choles this past week). Another trick to remember is to use the operating laparoscope and the long Metzenbaum scissors (that go through the operating scope)--you can take down quite a few adhesions through the umbilical puncture site with this combination.

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Treatment guru

Re: Lap chole after previous lap - Ärzteforum

Post#7 »

In a case like this, I usually use a US Surgical Visiport through a vertical incision just above the umbilicus.

Chirurgia

Re: Lap chole after previous lap - Ärzteforum

Post#8 »

Lap surgery is not a matter of surgical bravado, machismo or vanity but patioent benefits. I suggest you read the literature!

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A Doctor

Re: Lap chole after previous lap - Ärzteforum

Post#9 »

I started off using the verres needle for my first few hundred cases but switched to the Hassan method for Lap Choles primarily because I find that I have to struggle less in getting the gallbladder out at the end of the case. With experience, entry in the abdomen is just as quick.

I reviewed the first 2,000 lap chole cases in Honolulu at 5 different hospitals (unpublished study). There were two small bowel injuries on entry. Both were during the use of a Hassan technique in patients with midline wounds. In this group of patients, the verres technique was not used for patients with midline incisions. The take home message that I got from this review, was that in patients with midline incisions, the open technique will not necessarily keep you out of trouble.

In patients with a previous midline, I feel that an alternative entry site is best. I usually use a verres in the midclavicular line and place a 5 mm scope through a 5 mm trocar to assess the periumbilical area and take down adhesions if necessary. When placing a verres needle in this location, it is vitally important that you both perform a drop test and aspirate the needle before insufflation. There have been cases reported of verres needles placed into the hepatic veins of the liver causing massive gas embolism.

For procedures besides gallbladders, I like to use the Optiview trocar by Ethicon. It is a direct viewing trocar like the Visiport by Autosuture that allows you to place the port into the abdomen under direct vision. Because it works by bluntly splitting the fibers of the fascia, the resulting trocar hole is smaller. It works wonderfully for massively obese patients. It also allows me to place the initial trocar any place I want. I am waiting for Ethicon the develop a 5 mm and 2mm version of the same product. I don't use it for my routine non obese gallbladder because again it is difficult to remove the gallbladder at the end of the case.

If you do use the open technique and encounter dense adhesions, you can generally use your finger in the hole to carefully bluntly dissect the adhesions from the anterior abdominal wall. This will give you some working room to insert another trocar with which you can place an instrument to takedown the rest of the adhesions.

Antibiotic

Re: Lap chole after previous lap - Ärzteforum

Post#10 »

My partner is also witty, "there are no new Heresies; there are no new surgical complications".

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