如何做腹腔镜手术减少腹部在开腹手术容易留下的疤痕？

How to do laparoscopy on an abdomen with previous laparotomy scar ?

Prof. Dr. R. K. Mishra

1. The open insufflation techniqueThe patient with previous abdominal surgery is at high risk for minimal access surgery in those patients following techniques should be used

Hasson technique

Fielding technique

2. Pneumoperitoneum should be created with a veress needle by selecting an alternate site of insertion distant from the old abdominal incision.

3 Insufflations with a veress needle inserted in posterior fornix or Trans uterus rout

4. Insertion of optical trocar- primary port.

Hasson's technique:

This is a very safe technique to enter the abdomen, especially in patients with scarred abdomen from multiple Previous surgeries.

This is an open technique where surgeon can see what he is doing. It is performed in an area of the abdomen distant from previous scars and likely to be free of adhesions. After the induction of anesthesia a one c.m horizontal incision is made. Blunt dissection is carried out until the underlying fascia is identified. The fascia is elevated with a pair of Kocher’s clamps. Adherent subcutaneous tissue is gently dissected free. It is then incised to permit entry of trocar into the peritoneal cavity. Two heavy, absorbable sutures are placed on either side of the fascial incision just like repair of umbilical hernia. Care must be taken when applying these sutures not to injury the underlying viscera. The Kocher clamps are next removed, and 10-mm blunt trocar is advanced into the peritoneal cavity. The obturator is removed and the sleeve is secured in position with the previously placed two sutures. The sleeve of the trocar is wrapped with Vaseline gauze to prevent leakage of insufflated gas around the trocar.

Open Fielding technique:

This technique developed by Fielding in1992 involves a small incision over the everted umbilicus at a point where the skin and peritoneum are adjacent. Pneumoperitoneum can be created using Fielding technique in patients with abdominal incisions from previous surgery providing there is no midline incision, portal hypertension and re-canalized umbilical vein, and umbilical abnormalities such as urachal cyst, sinus or umbilical hernia present. A suture is not usually required to prevent gas leakage because the umbilicus has been everted (so the angle of insertion of the laparoscopic port becomes oblique) and the incision required is relatively small. However, one may be needed to stabilize the port. Thorough skin preparation of the umbilicus is carried out and the everted umbilicus (with toothed grasping forceps) is incised from the apex in a caudal direction. Two small retractors are inserted to expose the cylindrical umbilical tube running from the undersurface of the umbilical skin down to the linea alba. This tube is then cut from its apex downwards towards its junction with the linea alba. Further blunt dissection through this plane permits direct entry into the peritoneum. Once the peritoneal cavity is breached the laparoscopic port (without trocar) can then be inserted directly and insufflations started. A blunt internal trocar facilitates insertion of this port and an external grip that can be attached to the port assist to secure it in position.

The advantages of using the open technique are many:

1.      The incidence of injury to adhesive although not eliminated is significantly reduced by entry into the peritoneal cavity under direct vision.

2.      There is a decrease risk of injury to the retroperitoneal vessels. The obturator is blunt and the angle of entry allows the surgeon to maneuver the cannulas at an angle, which avoids viscera, while still assuring peritoneal placement.

3.     The risk of extra peritoneal insufflations is eliminated. Placement under direct vision ensures that insufflation of gas is actually into the peritoneal cavity.

4.     The likelihood of hernia formation is decreased because the fascia is closed as part of the technique

5.      In experience hands the open technique is cost effective. The Hasson technique does not increase the   operative time required creating a pneumoperitoneum and may even lessen it.

Alternative sites for introducing veress needle.

For avoiding the injury to the adhered portion of bowel in the patient with previous abdominal surgeries the alternative site for the introduction of veress needle can be choose other than umbilicus.

For Previous laparotomy with midline incision:

For a previously operated abdomen with a midline incision, Veress needle should placed in the upper left quadrant of the abdomen just lateral to the rectus sheath. The preperitoneal space in hypochondriac region is more easily insufflated than at the umbilicus. The veress needle at hypochondriac region need to be passed more deeply into the abdomen in order to enter the peritoneal cavity because all the layers of abdomen are present here and there is a thick layer of muscle as well. The right upper quadrant should be avoided because of the size of the liver and the presence of the falciform ligament. There is some report of injury to liver if the liver is enlarged or the careless insertion of veress needle to right hypochondrium is performed.

For a previous laparotomy with upper midline incision:

In a patient with scar on the upper midline of abdomen the veress needle should be placed in the right lower quadrant, the left lower quadrant should generally avoided since in older patients there are usually sigmoid adhesions in the left lower quadrant.

For previously operated abdomen with a solitary incision in an upper or lower abdominal quadrant.

In a patient with the scar in the upper or lower abdominal quadrant the Veress needle should be passed in the opposite abdominal quadrant just lateral to the rectus muscle. The left lower and light upper quadrant should be avoided if it is possible. For patient with previously operated abdomen in multiple quadrants: In these patients a veress needle or open cannula in an area farthest from the existing abdominal scar should used. When there is any confusion regarding the presence of adhesion inside the abdomen where veress needle has to go, the open-cannula technique should be used.

TRANSUTERINE INSUFFLATION:

Some surgeons prefer to introduce veress needle through the posterior fornix or though uterus in female with previous abdominal surgery. Although this method of pneumoperitoneum is now very popular the placement of a needle via the posterior fornix has been demonstrated to be safe. If this rout of pneumoperitoneum has been chosen than the needle must be placed in the midline about 1.75 cm behind the junction of the vault and smooth epithelium of external OS.

                               
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Rout of insufflation.

Insufflation with an Optical trocar (Visiport)

This is one of the techniques used for performing laparoscopic procedures in patient with previous scarred abdomen. An incision of 1 cm long is made in the area of the abdominal wall distant from the previous scars. The littlewood forceps is used to elevate the abdomen. The Visiport optical trocar is introduced with telescope. The optical trocar is advanced slowly through the different planes of the abdominal wall. The blade at the tip of the visiport cuts the tissue which is visible also and there is very less chance of injury to intra-abdominal organ if the surgeon is experienced.

总的来说，就是一点，就是远离手术部位，开放式的建立气腹。