When and how to perform a safe direct entry of a laparoscopic trocar

In this video, we show the indications, technique and contraindications of direct port entry in laparoscopic surgery. Although this way of entry is not popular, recent data show that there are no differences in terms of safety for a way of entry (i.e., Veress needle, open laparoscopy, Hasson's technique, direct entry, etc.) when compared to another. We also discuss some hints and tips and tricks to use when performing this entry technique.

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When and how to perform a safe direct entry of a laparoscopic trocar

Authors

E Kovoor, I Miranda-Mendoza, J Nassif, A Wattiez, J Marescaux

Abstract

In this video, we show the indications, technique and contraindications of direct port entry in laparoscopic surgery. Although this way of entry is not popular, recent data show that there are no differences in terms of safety for a way of entry (i.e., Veress needle, open laparoscopy, Hasson's technique, direct entry, etc.) when compared to another. We also discuss some hints and tips and tricks to use when performing this entry technique.

Classification

tips and tricks

Keywords

Direct port entry in laparoscopy

Media type

Surgical video

Duration

03'23''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2747.htm

When and how to perform a safe direct entry of a laparoscopic trocar

1. Patient position and identification of avascular areas 00'31''

The following video demonstrates our technique of direct entry. The patient is placed in a supine position without any tilt. It is important to identify the avascular areas. The landmarks are identified as shown. The anterior iliac spines are here. The lateral borders of the rectus muscles are identified. There are three safe avascular triangles as shown here. The two lateral triangles are between the lateral border of the rectus sheath and the iliac spines. This is the site for the lateral ports. The third triangle is in the suprapubic region between the two umbilical arteries and the base of the bladder. The epigastric vessels are shown here going superiorly and they remain medial to the lateral triangles.

2. Umbilical incision and trocar placement in the incision 01'20''

The umbilical incision is made on the left lateral border of the umbilicus parallel to the abdominal wall. We use a standard reusable metallic trocar with a valve. The trocar should be held as shown with the tip of the index finger about three centimeters away from the tip of the trocar. The trocar should be kept open during insertion. The first trocar is placed at 90 degrees to the abdominal wall through the incision. The assistant and the surgeon grasp the abdominal skin below the umbilicus but do not lift up the skin completely. Now the surgeon drives the trocar firmly towards the rectus sheath.

3. Direct entry 02'06''

Once the rectus sheath is reached, the abdominal skin is lifted up so that a flap is formed that is 90 degrees to the abdominal wall. By keeping the trocar fixed on the rectus sheath, the trocar is now driven through the rectus sheath in a slow and firm twisting motion. The trocar’s orientation is at 90 degrees to the flap of skin, which will be in the direction of the pelvis. Once you feel the resistance of the rectus sheath giving way, do not accelerate but continue with the same speed until you feel entry of the peritoneum. As you can see, the trocar needs to go in only by about 3cm to enter the peritoneal cavity. The position of the scope must be checked first before starting insufflation. Once insufflation is started, you obtain a good view very quickly. As this video shows, direct entry in selected patients is safe and easy to perform.