Palmer’s point : two fingerbreadths below the left costal margin in the midaxillary line
Regardless of the technique chosen for entry, the first step following port placement should be a visual inspection of the abdomen for injury. This can include the obvious, such as bleeding or enteric contents or the subtle, such as a retroperitoneal hematoma or hollow viscus injury. Any failed entry site should be inspected to assess for any associated injury. Hollow viscus injury may be repaired with oversewing as appropriate. Small bleeding can be controlled with an energy device. Larger bleeding may require vascular repair, and early consultation from a vascular surgeon is recommended. Bladder injury may require closure in layers and use of a Foley catheter for decompression for an extended period postoperatively. Urology consultation is recommended.
Laparoscopic entry can cause injury to vessels of the abdominal wall. Access sites are carefully chosen to avoid major vessels. Abdominal wall bleeding may not be immediately apparent until after the port is removed because the port may tamponade muscular or subcutaneous bleeding. In addition to visually inspecting the access site upon its creation, all laparoscopic port sites should also be observed during and following port removal. Bleeding points can usually be identified and managed with electrocautery or sutures as necessary. If bleeding persists, a Foley catheter may be inserted, inflated, and pulled back against the abdominal wall to tamponade the site. U-stitches can then be placed into the abdominal wall under direct laparoscopic visualization using a suture passer with absorbable braided suture. With uncontrolled bleeding, the skin incision may need to be enlarged to control the bleeding. Both proximal and distal to the injured portion of the vessel must be sutured.
Poor insufflation/loss of pneumoperitoneum
CO2 tank empty
Accessory port stopcock(s) not properly adjusted
Inspect all accessory ports. Open or close stopcock(s) as needed
Leak in sealing cap or stopcock
Change cap or cannula
Allow time to reinsufflate
Loose connection of insufflator tubing at source or at port
Hasson stay sutures loose
Replace or secure sutures
Tubing disconnection from insufflator
Flow rate set too low
Adjust flow rate
Excessive pressure required for insufflation (initial or subsequent)
Veress needle or cannula tip not in free peritoneal cavity
Reinsert needle or cannula
Occlusion of tubing (kinking, table joints, etc.)
Inspect full length of tubing. Replace with proper size as necessary
Port stopcock turned off
Fully open stopcock
Patient is “light”
Give more muscle relaxant
Cannula tip not in peritoneal space
Advance cannula under visual control
Inadequate lighting (partial/complete loss)
Loose connection at source or scope
Light is on “manual-minimum”
Go to “automatic”
Bulb is burned out
Fiber optics are damaged
Replace light cable
Automatic iris adjusting to bright reflection from instrument
Reposition instruments or switch to “manual”
Monitor brightness turned down
Room brightness floods monitors
Dim room lights
Lighting too bright
Light is on “manual-maximum”
Go to “automatic”
“Boost” on light source is activated
Monitor brightness turned up
No picture on monitor(s)
Camera control or other components (printer, light source, monitor) not “on”
Make sure all power sources are plugged in and turned on
Cable connector between camera control unit and/or monitors not attached properly
Cable should run from “video out” on camera control unit to “video in” on primary monitor. Use compatible cables for camera unit and light source
Cable between monitors not connected
Cable should run from “video out” on primary monitor to “video in” on secondary monitor
Input select button on monitor doesn’t match “video in” choice
Assure matching selections
Poor picture quality
Condensation on lens from cold scope entering warm abdomen
Gently wipe lens on viscera; use antifog solution or warm water
Condensation on scope eyepiece, camera lens, coupler lens
Detach camera from scope (or camera from coupler), and inspect and clean lens as needed
Flickering electrical interference
Moisture in camera cable connecting plug
Use suction or compressed air to dry out moisture (don’t use cotton tip applicators on multipronged plug)
Poor cable shielding
Move electrosurgical unit to different circuit or away from video equipment
Insecure connection of video cable between monitors
Reattach video cable at each monitor
Adjust camera focus ring
Cracked lens, internal moisture
Inspect scope/camera, and replace if needed
Adjust enhancement and/or grain settings for units with this option
Low pressure can be due to several etiologies. First, check that the CO2 tank is full and that all lines and stopcocks are open or closed as appropriate. Next, check to make sure the ports are not leaking. If a port leaks during surgery, it can be due to the fascial defect being too large or excessive port angulation . Leaks can also be decreased with additional sutures or the placement of a towel clamp to cinch the tissue closed around the trocar. Petrolatum-coated gauze may also be used to reduce the flow of any air leak. If available, balloon-tipped trocars can be used to eliminate a leak.
High pressure can result from several factors. Begin by inspecting insufflation tubing and stopcocks and that the insufflator is set on the correct pressure. High pressure can also be a result of the patient being inadequately paralyzed. Discussion with anesthesia regarding redosing of muscle relaxant is appropriate.
Investigation of poor lighting begins with tracing the light cord back to the light source and ensuring an appropriate connection. The light source itself should be checked and make sure the bulb is lit. The laparoscope should be cleaned to remove any material that may block the light. Finally, consider replacing the light cord as the fiber-optic cables can crack over time.
Troubleshooting an inadequate picture on the monitor involves a number of steps. As with the above issues, first start by tracing the camera cord and ensuring all cables are plugged in to the appropriate sites. The camera connection with the laparoscope should be examined and made sure it is tight. The laparoscope should be cleaned of any debris. If these measures fail, first replace the camera and then the laparoscopic tower.
Should any of these measures fail to fix the problem, the local representative of the laparoscopic equipment should be contacted for assistance.
Laparoscopic surgery utilizes gas (usually CO2) to insufflate the abdominal cavity to supernormal intra-abdominal pressures. The elevated intra-abdominal pressure, along with patient positioning and carbon dioxide absorption, can cause changes in physiology, especially in the respiratory and cardiovascular system. In most instances, the body can adapt to these changes without significant issues. But in certain scenarios, physiologic changes may become life threatening.
Nodal rhythm, sinus bradycardia, and asystole can all result from stretching of the peritoneum. Such effects usually take place at the beginning of insufflation because of the rapid stretching of the peritoneum. Should any arrhythmias be noted, immediate communication between the anesthesia and surgery team should take place. The abdomen should be desufflated as quickly as possible, and pharmacologic correction of the arrhythmia should be initiated.
The most frequently used gas for insufflation is CO2. It is colorless, nontoxic, and nonflammable and has the greatest margin of safety in the event of a venous embolus as it is highly soluble. As it is readily absorbed from the peritoneum, it can cause an increase in PaCO2. This has direct, as well as indirect (by raising catecholamine levels), effects on the cardiovascular system. Tachycardia, increased cardiac contractility, and reduction in diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischemia. Constant monitoring of the ECG rhythm strip for signs of ischemia is essential. Any evidence of ischemia should be communicated, and the abdomen should be desufflated promptly.
If CO2 is insufflated directly into a blood vessel or if gas is drawn into an open vessel by the Venturi effect, venous gas embolism can occur. This is a rare but potentially fatal occurrence. The physiologic effects of carbon dioxide are less than that with air because of the greater blood solubility. The clinical signs of a venous gas embolus begin with an abrupt decrease in the end-tidal CO2 levels and are accompanied by hypotension and desaturation. A “mill wheel” murmur may be auscultated on physical exam. A transesophageal echocardiogram is usually required to evaluate the embolism. Treatment includes rapid deflation of the abdomen placement of the patient in the left lateral Trendelenburg position and resuscitation. If severe, the gas can be aspirated with a central line.
Optimizing Laparoscopic Exposure
OR Table Positioning
Obtaining proper exposure is one of the key elements to successful completion of any surgical procedure. As opposed to open surgery, where retractors can be easily placed, laparoscopic surgery presents more of a challenge. Gravity remains the greatest retractor available to the laparoscopic surgeon, and its use requires safe manipulation of the operating table to achieve exposure of the intended operative field. Mobilization of the splenic flexure can be aided by placing the patient in reverse Trendelenburg; rectal surgery is aided by placing the patient in Trendelenburg. Additional exposure can be provided by rotating the operative bed to the right or the left. Beyond gravity, additional ports and intraperitoneal retractors can be helpful as well. Position changes and additional retractors all introduce new complexities to the operation and provide opportunities for complications. Appropriate foreknowledge of these pitfalls can help to avoid them.