The first step in most abdominal laparoscopic procedures is insufflation of the intraperitoneal space with CO2 gas and the introduction of the videoscope system. The original and most established technique uses the Veress needle, as described in the preceding Plate 90. The Veress needle can be placed in any quadrant of the abdomen, but it is most frequently inserted just below the umbilicus, where a skin incision has been made for the introduction of a large 10-mm port for the videoscope. General surgeons, however, have been cautious in adopting this technique of blind puncture, as their training has emphasized the importance of complete visualization of anatomy and of the planned action of their surgical instruments. Accordingly, the open or Hasson technique for entering the abdomen under direct vision has become more popular and safer. This technique can be used to enter into any quadrant of the abdomen but is most commonly employed at the central umbilical site (Figure 1). A vertical or transverse skin incision approximately 10 to 12 mm in length is made just below (Figure 2) or above the umbilicus. The choice of site may be based on the surgeon's preference or the presence of a previous regional incision that may have adhesions. The subcutaneous fat and tissues are bluntly dissected apart using small narrow finger retractors or a Kelly hemostat. The white linea alba is visualized and grasped on either side with hemostats. The linea alba is elevated with the hemostats and a vertical 10-mm incision is made through the fascia (Figure 2). Further dissection with a hemostat will reveal the thickened white peritoneum, which is grasped with a pair of laterally placed hemostats (Figure 3). The peritoneum is elevated and opened cautiously with a scalpel. A dark, empty peritoneal space is seen and a pair of lateral stay sutures are placed. These sutures incorporate the peritoneum and linea alba and are later used to secure the Hasson port.
The next step is to verify that the intraperitoneal space has been entered freely. The surgeon's fifth finger is inserted (Figure 4). This maneuver sizes the hole for the port and allows the surgeon to palpate the region. Usually this space is clear, but on occasion there are some filmy omental adhesions that can be swept away. The Hasson port with its blunt, rounded-tip obturator is introduced into the abdomen (Figure 5). The spiral collar is screwed into the fascia so as to provide a snug gas seal, and the lateral stay sutures are secured to the notches on the collar. The obturator is removed. The CO2 line is attached and the stopcock opened. The surgeon sets the rates of CO2 flow and maximum pressure (15 mmHg). He or she observes the intra-abdominal pressure and the total volume of CO2 infused as the abdomen enlarges and becomes tympanitic. The videoscope is white-balanced and focused. The optical end of the instrument is coated with antifog solution. The videoscope is introduced into the port and advanced into the peritoneal space. If an angled optical instrument, typically 30 degrees, is used, it is important for the operator of the videoscope to establish the correct orientation of the optics and the video head. Typically, the optical bevel is downward-viewing (6 o'clock) when the fiberoptic light cable is vertical (12 o'clock). The video head is correctly oriented when its cable is positioned at 6 o'clock posteriorly. Rotation of either instrument from these positions will produce a rotated view on the TV monitor.
In the presence of omental adhesions or an enlarged falciform ligament, the intraperitoneal space may not easily be entered as the videoscope comes to the end of the Hasson port. If this area was clear to palpation with the surgeon's fifth finger, careful angulation and rotation of the videoscope usually finds the right opening. When the opening cannot be found, the port is removed and a repeat finger palpation is performed before reinsertion of the Hasson port. In extreme cases, when finger palpation cannot find an easy intraperitoneal entrance because of dense adhesions, an alternative site for the Hasson port should be used.
The usual alternative sites (Figure 1) are in the four quadrants of the abdomen, although the Hasson port can also be placed through the midline linea alba in the epigastric or suprapubic regions. A transverse skin incision is made and the subcutaneous fat spread with narrow finger retractors or a Kelly hemostat. The fascia of the external oblique muscle is incised with a scalpel. Further deep dissection is performed through the internal oblique and transversus muscles, whose thin fascia usually does not require incision. The white peritoneum is grasped between hemostats and elevated. A scalpel incises the peritoneum and a clear entry into the intraperitoneal space is verified by deep passage of a Kelly hemostat. A pair of lateral stay sutures incorporating the peritoneum and fascia are placed. The remainder of this procedure is performed as described for the umbilical site.
Most 5-mm port sites do not require suture closure of the fascia, especially if the port is passed originally in a zigzag or oblique manner through the muscle layers of the abdominal wall. On occasion, however, a blood vessel of the intra-abdominal wall that was not seen with transillumination may be cut by the trocar during the placement of a port. Most small vessels will stop bleeding. However, some may continue to drip into the intraperitoneal space and obscure visualization. A technique for the control of these vessels or for closure of a fascial defect is shown (Figure 6). A 00 delayed absorbable suture is placed into the tip of a special suturing needle. The needle and suture are passed through the inner abdominal wall about 1 cm beyond the edge of the port entry site (Figure 6A). The suture is released from the needle tip with a long free end showing within the abdomen. The special suturing needle is removed and reinserted about 1 cm beyond the opposite edge of the port entry site. The needle tip is opened and the suture is grasped (Figure 6B). The free end of the suture and the needle are withdrawn. The suture is tied down through the skin opening. This technique produces a mattress suture that can secure abdominal wall blood vessels or close fascial defects created by the placement of large ports. Both maneuvers are done under direct visualization using the videoscope.