Laparoscopic Entry Using a 90° Approach and the Surgical Community in Which They Were Done—a Review of 5395 Cases

Entry into the peritoneal cavity in performance of laparoscopy has been and remains a problem for surgeons. It contributed to failure accomplish intended surgery injuries gastrointestinal tract, urinary vascular system. Various techniques have described laparoscopic entry, but none support use any one technique over another [1Ahmad G Baker J Finnerty Phillips K Watson A Laparoscopic entry techniques.Cochrane Database Syst Rev. 2019; 1CD006583PubMed Google Scholar]. This report will describe entire experience author using 90° angle that he previously [2Loffer FD Pent D An alternate penetrating abdomen laparoscopy.J Reprod Med. 1974; 13: 37-40PubMed Cases are broken down between those solely managed by were done teaching situation with trainees who practicing gynecologists or gynecologic residents. Following demonstration case author, they had first opportunity enter abdominal cavity. As most situations, might varying degree participation actual entry. The his associate, David Pent, MD, performed their on May 5, 1970. At time, there no training programs 3 monographs available English used as instruction guides [3Steptoe PC Laparoscopy Gynaecology. Edinburgh: E & S Livingston Ltd, 1967Google Scholar, 4Cohen MR Laparoscopy, Culdoscopy Gynaecography. W. B. Saunders Company, Philadelphia1970Google 5Frangenheim H Gynecology. Butterworth, London1971Google To enhance our self-teaching, many cases co-surgeons. was staff 2 private hospitals Maricopa county hospital, all which Phoenix each accredited residency Obstetrics implemented residents programs. Arizona's only medical school Tucson. faculty appointment responsible students rotated through Phoenix. offered unique feature allowed author's collection these cases. founding anesthesiologists Surgicenter February free stand surgical facility United States later extensively copied. soon recognized an inpatient hospital setting not necessary Surgicenter's December From time onward, outpatient facilities preferred choice locations [6Loffer Hospitalization – exception rather than rule.Obstet Gynecol. 1977; 49: 625-627PubMed decision be at other dictated insurance requirements, clinic cases, already hospitalized patients, request patient's primary care physician because major comorbidities, when high probability diagnostic would require laparotomy. Early experience, either diagnosis pelvic pathology sterilizations. pent-up demand this new female sterilization technique. formed Arizona Family Planning Service offer sterilizations women “who did could afford care.” federally 501 (c) (3) organization. Participating surgeons, anesthesiologists, received prearranged fee substantially less practice charges. 1971 1981, supported 49 postgraduate courses associate gave gynecologist. These 3-day gynecologist actually perform surgeon. attended more 550 from 46 states 4 foreign countries. All course fees went patient care. remaining local They trained without charge professional colleagues. institutional review board St. Joseph's Hospital Medical Center determined intervention interaction identifiable information utilized [45CFR46.102(e) (1) (i–ii)]. Outpatient charts completed required further used. Temporary worksheets created laparoscopies record pertinent operative data. transferred spreadsheets reported paper type undertaken. spreadsheet contained identifying information. Only access input spreadsheet. Two data points definition. Appendectomy incisions (except several ruptured appendix) considered incision (and therefore risk factor) because, adhesions seldom found site previous appendectomy. Intra-abdominal (i.e., scarring tubes ovaries omental limited structures) counted. Scholar] insertion Veress needle trocar combined elevation wall towel clips helps avoid preperitoneal placement providing conical space is safe distance underlying structures (Fig. 1, Fig. 2). often-described lifting hand potentially decreases can develop. being requires anesthesia must allow raised minimal resistance. In addition, should remain flat Trendelenburg until entered telescope.Fig. 2A inserted lying raising (An Alternate Technique Penetrating Abdomen Laparoscopy).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Control during maintained resting against wrist action 3). Proper confirmed demonstrating “negative pressure.” achieved determining, before insertion, inherent pressure generated rate carbon dioxide flowing needle. Then, tubing attached stopcock closed. Upon opening briskly elevating wall, observed insertion. If doubt placement, position changed 4). closed, replaced 5 cc syringe whose plunger removed. filled saline. When reopened, saline drain spaces. changing needle's position; closing stopcock; replacing aspirating again. No returned it flowed cavity.Fig. 4A method holding both partial pneumoperitoneum Safe cannula lower umbilical fold deep umbilicus 5). pieces held together palm surgeon's hand, index finger placed alongside shaft. acts brake elevated sudden penetration occur. drilling motion Occasionally, obese temporarily increase intraabdominal routinely incrementally slowly change toward pelvis. total 5395 1970 2004 recorded. included. Access accomplished series. Pelvic scaring occasionally precluded viewing some structures. breakdown series Table 1. There history 1128 (20.9%) anterior near 573 patients (10.6%). Bowel included 40 (0.7%).Table 1History findings adhesionsVariablesAll patients*Percentages given relate complete (%)Teaching pts†Percentages numbers group. (%)Nonteaching (%)Number pts5395 (100)2278 (42.3)3117 (57.8)Previous abd surg1128 (20.9)481 (42.7)647 (57.3)Ant adhesions1128 (57.3)Bowel attached40 (0.7)10 (0.4)30 (1.0)Abd = abdomen; ant anterior; pts patients; surg surgery. Percentages series.† Open table tab Abd Teaching (42.3%) involved. may surgeries assist. temporary worksheet quantifying trainee's role, after demonstrated technique, generally attempt subsequent problems ever author. 1 unplanned laparotomy related occurred inability procedure Perforation uterus tip uterine manipulator uncommon never resulted problem. Several troublesome epigastric vessels bleeding ancillary site, observation. None transfusions. early learning curve attempted short stature weight 250 pounds. Similar excluded obtained [7Loffer patient.Am Obstet 1976; 125: 104-107Abstract Full Text PDF PubMed Scopus (55) Three weighed 300 Their weights pounds 312, 328, 355, respectively. difference number nonteaching (Table 1) possibly reflects avoidance chosen participate program Service. higher body mass indexes group reflected population hospitals. Raising contributes success probably factor bowel adherent belief plate hang like curtain raised. instruments then tend parallel adhesions. suggested thin greater injury. allows safely also very 2).Table 2Distribution groupVariablesNo. ptsAll pts*Percentage relates pts†Percentage (%)BMI53952278 (42.2)3117 (57.8)Underweight<19334 (6.2)129 (5.7)205 (6.6)Average19 243738 (69.3)1519 (66.7)2219 (71.2)Overweight25 29751 (13.9)345 (15.1)406 (13.0)Obese30 39489 (9.1)238 (10.4)251 (8.1)Extreme obesity40 6083 (1.5)47 (2.1)36 (1.2)BMI index; =patients. Percentage BMI strength describes results large suggests easily adapted others. role reduced bias reporting single familiar. weaknesses report. cannot assumed aspects trainee. Therefore, possible statistically compare Furthermore, under direct supervision similar good results. Another weakness postoperative complications does include follow-up seems unlikely size closeness community fact legal liability issues conclusion, described, even multiple successful acknowledged fortunate occur eventually one. Although guarantee success,