Laparoscopic Surgery: What is it?
Surgery is quickly moving toward less and less invasive ways to perform the necessary procedures. Laparoscopic surgery is now pretty standard for most cases - unless altered anatomy or safety issues brings us to open. I've given the spiel over and over again that we make tiny incisions that we insert ports and instruments into, all under direct visualization of a port camera. But how do we make the initial entrance to the abdomen?
There are two approaches, veress and hasson.
Veress is the closed approach, in which a 5mm incision is made in the skin and subcutaneous tissue, all the way down to the fascia. The abdominal wall is elevated via the skin with graspers and a veress needle is inserted at a 45 degree angle toward the hollow of the pelvis or away from fixed viscera. Not a perfect science, but after feeling 2 pops (1st is through the abdominal fascia, second is through parietal peritoneum), you're in the abdominal cavity.
We then attach a 10ml syringe with normal saline to the hub - in which we aspirate to make sure no blood returns, inject saline (which should fall into the peritoneal space easily, without resistance). We then connect the CO2 gas and measure the intraperitoneal pressure. In most people, it's around 5mmHg, but it should be below 10mmhg. We insufflate the abdomen until about 15mmHg and with this we have space to work within the abdomen.
We remove the veress needle and place a primary port in the needle track, by twisting the trocar in with a firm, downward pressure. We then insert the camera to examine our entry point to ensure no damage was done to internal organs or structures, then proceed to other port placements.
Hasson, on the other hand, is where we make a 10-12mm skin incision, just below or above umbilicus. We then bluntly dissect the subcutaneous tissue with a clamp, cauterize any vessels, until the linea alba is visualized. Either side is grasped with hemostats, elevated, and a vertical 10mm incision made through fascia. Dissection reveals thickened white peritoneum, which is grasped with pair of laterally placed hemostats. The peritoneum elevated and opened cautiously with a scalpel.
A pair of lateral stay sutures are placed, which is later used to incorporate the peritoneum and linea alba to secure the Hasson port. A finger is inserted, used to sweep underside of abdominal wall with index finger to clear of bowel/omentum, and a blunt-ended trocar is placed through incision. The CO2 insufflation is the same as above with veress.
We perform the surgery by using long instruments that we insert into these ports, while visualizing the inside of the abdomen on TV screens. As you can imagine, 3D organs and structures in space that are displayed on a 2D Screen requires some adjustments, and it's much like playing a video game. Moving screen left is body right, and depth perception may make grasping objects or fine motor skills more difficult than you can imagine.
When finishing, most of the CO2 is exonerated from the abdomen with some slight pressure before removing the ports. The 12mm port site fascia is closed primarily and then the skin is sutured after it. Of note, most 5mm port sites don’t require suture closure of fascia, especially if the port passed originally into a zig zag or oblique manner through muscle layers. But, we usually close them with one suture and then skin glue.