Fig. 10.1
Intraperitoneal Veress needle confirmation
In the open technique , the abdominal cavity is approached passing through each of the layers until the peritoneal cavity is reached. No step is completed blindly; therefore, theoretically it offers advantages such as certainty of establishing peritoneum, anatomic repair of the facial incision, elimination of the risk of gas embolus, and reduction in vascular and bowel injuries related to the initial access [11].
According to some studies, the open technique eliminates the risk of major vascular injury and reduces the rate of major visceral injuries. However, the study of a higher level evidence of Cochrane database concluded that no significant differences in the incidence of injury between both techniques were found [12].
The visual entry technique accesses the abdominal cavity with a specialized optical port that has a conical nonbladed transparent tip, allowing each layer of the abdominal wall to be seen with a 5 mm 0-degree laparoscope as it is being traversed (Fig. 10.2). A firm, constant alternating clockwise–anticlockwise motion is used. According to Thomas et al., despite each layer of the abdominal wall is displayed, the use of this device does not remove intra-abdominal injuries [13]. The combination of pneumoperitoneum with closed method followed by the optical trocar placement is an excellent choice.
Fig. 10.2
Abdominal wall layers identified during optic trocar introduction
Each surgeon should choose the method that s/he feels more comfortable with and s/he has more experience with, but should be familiar with alternative techniques.
Nasogastric Tube and Foley Catheter
The placement of a nasogastric tube to decompress the stomach reduces the likelihood of gastrointestinal injuries, in operations involving port placement in the lower abdomen is also recommended to empty the bladder using a Foley catheter ; this also allows an early detection of injuries. The presence of air or hematuria in the urine collecting bag should be considered a suspected bladder injury [14].
Palmer’s Point
Palmer’s point is located in midclavicular line 3 cm below the rib in left upper quadrant. This is a point where in theory the probability of abdominal adhesions is considerably lower than the rest of the abdomen, which is the best option in the case of patients with a history of abdominal surgery [15] (Fig. 10.3).
Fig. 10.3
Palmer’s point ubication
If Palmer’s point is used, it is especially necessary to empty the stomach using a nasogastric tube. This point should not be used in patients with a history of splenectomy, gastric surgery, or in the presence of hepatosplenomegaly.
Primary Trocar Placement
If the open technique has been used, the trocar is already on the site, which is an advantage because a blind step was avoided.
If the pneumoperitoneum was created using the Veress needle, the entry of the primary trocar is carried out following these recommendations: Oblique direction, introduce with the valve open, as the escape of pneumoperitoneum through this, is a sign of intraperitoneal location. The pressure of the pneumoperitoneum can be temporarily increased for this first port placement; such temporary increase proves no hemodynamic impact on the patient [6]. Once the port is placed, the camera is introduced to confirm a proper location and to examine the abdominal cavity.
This first port placement by using an optical trocar is an option that requires experience, has shown to decrease the time required for the initial approach and the creation of pneumoperitoneum, yet this technique is not free of complications [16].
Secondary Trocar Placement
Injuries can occur during secondary trocar insertion. The number, size, and portion of these trocars are dictated by the procedure being done. Transillumination technique helps avoid bleeding produced by vessel injury on the abdominal wall. In any case, ports should be introduced under direct vision with special care to identify and avoid epigastric arteries.
There are different robotic trocars obturators: sharp, bladeless, and blunt (Fig. 10.4). The use of noncutting trocars has shown advantages over the incidence of bleeding in the abdominal wall, postoperative pain, and patient satisfaction. However, trocars require much more application of force for insertion, which can potentially increase the rate of injury [17].
Fig. 10.4
Robotic trocar obturators
Other Considerations in Robotic Surgery
Remote center: Trocar location with the remote center in proper position is particularly important to reduce postoperative pain and increase patient satisfaction. However, trocar location at the appropriate point should not become a limiting factor when carrying out the procedure or in specific situations that require going further or retract the trocar.
Tension in the abdominal wall: Once the robot arms are connected, it is important to release the tension on the abdominal wall to prevent injuries and reduce postoperative pain.
Avoid external conflict and clash with limbs: The movement of robot arms must be verified during the procedure, so that arms do not clash each other. Also, it is important to be certain that they will not clash with patient’s limbs or with costal arches to avoid injuries.
Diagnosis and Treatment
The incidence of bowel and vascular injuries is quite low. However, a major vascular injury or an unrecognized bowel injury may carry a significant increase in morbidity and mortality. Complications and its prevention are summarized in Table 10.1.
Table 10.1
Prevention of complications in portals placing and management
Complication | Prevention | Management |
|---|---|---|
Vascular lesion | – | – |
Abdominal wall | Transillumination | Direct pressure rotating the tip of the trocar |
Visualization of the epigastric vessels | Insert Foley catheter | |
Secondary trocar introduction under direct vision | Place U stitches with the suture passer | |
Removal of trocars under direct vision to verify hemostasis | Extend the skin incision | |
Use of monopolar, bipolar, or ultrasonic energy for hemostasis control | ||
Intra-abdominal | Trocar introduction under direct vision | If serious vascular injury is suspected, conversion to an open procedure must be considered |
Proper technique | Direct compression of the bleeding site | |
Open access | Increase insufflation pressure
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