The concept of non-umbilical first blind port laparoscopic entry

Nutan Jain, Vandana Jain, Aruna Arya, Shalini Singh, Apoorva Walia, Richa Kallia
2021 Obstetrics & Gynecology International Journal  
As minimal access surgery is having an upper edge over laparotomy not only for simple cases, but also for larger masses and gynaecological malignancies. Many gifted surgeons are in elite class of removing very large myomas and uterus laparoscopically. 5, 6 Other complex laparoscopic entries are made in clinical situations of previous surgeries done either laparoscopic or via laparotomy. Still more complex situations are laparoscopic removal of big masses with previous surgeries, and dealing
more » ... e malignancies. 7 As there is liberalization of caesarean section as a route of child birth, the situation of co-existent previous surgery in clinical indications for gynae laparoscopy are faced very often, like TLH with multiple previous caesarean sections. Rise in infectious pathologies; in gynae patients give rise to more adhesions, tubal blocks and then infertility that necessitate a laparoscopy. With the clinical scenario of previous surgeries, big masses, infectious pathologies and complex scenarios of combinations of these, laparoscopic entry poses certain challenges. Another challenge is also on rise -Obesity ǃǃǃ As the global incidence of obesity rises, gynae endoscopist find more patients in the obese and morbidly obese groups. [8] [9] [10] So, however accomplished endoscopic surgeon is first blind entry in afore mentioned clinical situations, alone or in combinations, pose a definite challenge. More ever unfortunately, 30-50% of the bowel injuries and 15-50% of the vascular injuries are not diagnosed at the time of injury. 1 This delay has contributed to mortality rates of 3-30% for bowel and vascular injuries. 11,12 As the clinical scenario is changing, we need to refine laparoscopic entry techniques to adapt to them with urgency, accuracy and aim towards reduction of entry related complications. Non umbilical entry port as the first blind port is a welcome concept. 13 All the situations described above, like a previous surgical scarred abdomen, large masses, previous infectious pathologies, thin patients and lax abdominal wall and obesity, all make umbilical entry unsuitable due to the high incidence of injury to vessels, viscera, and adhered bowel. Due to anatomical location of umbilicus which lies typically between the 3rd and 4th lumbar vertebrae or opposite the 4th lumbar vertebra with a variable range between 3rd and 5th lumbar vertebrae among different individuals. The aortic bifurcation in most of the individuals, also rests between the 4th and 5th lumbar vertebrae and within 1.25cm above or below the highest points of the iliac crests. 14 In very thin woman, especially one with an android pelvis and prominent sacral promontory presents specific hazards, as the depth of the umbilicus lies within 1-2cm of the anterior surface of the aorta. It is found that in thin patients, the distance between the abdominal wall and the retroperitoneal vessels may be less than 2 cm. Hence thin patients are more vulnerable to major vascular injury. 15,16 Also, the distal aorta and right common iliac artery are particularly vulnerable to injury since the junction of these two vessels is directly below the umbilicus. 15, 16, 17 Thus, the relation of this retroperitoneal vasculature to the laparoscopic trocar insertion site must be very carefully considered before starting any laparoscopic surgery (Figure 1) . 18, 19 In the previous surgeries the risk of adhesions at umbilicus ( Figure 2 ) could vary from 0% to 68% in those without any previous abdominal surgery, 0% to 15% in those with previous laparoscopy, 20% to 30% in those with previous laparotomy through a low transverse incision and 30% to 50% in those with a previous midline laparotomy. [20] [21] [22] [23] According to Ellis et al and Liakakos et al postsurgical adhesions are seen in 67-93% patients after general surgical operations and 70-95% patients undergoing major gynaecologic surgery. 24, 25 Large masses which rise above the umbilicus, carry the risk of being directly hit by first blind trocar from umbilicus. In myomas it can cause bleeding and in case of cystic masses it can cause rupture of the cyst even before gaining access, 26,27 and if malignant also carry the risk of upstaging the tumour due to spillage of cyst contents. Hence it will be prudent to use a non -umbilical approach. All this discussion clearly points to adopting a non-umbilical approach in more advanced situations. As we consider the concerns of major vessel injury via direct hit through veress or trocar or visceral injuries in case of bowel adhesions. May be, if we adopt the first blind entry through nonumbilical approach especially in vulnerable cases, we can avoid lot of complications due to the umbilical entry.
doi:10.15406/ogij.2021.12.00583 fatcat:mwnnavmx4fgdxkumlkpqjv4pay