Non-Umbilical Laparoscopic Entry Ports Nutan Jain
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
Abdomen 47, 72, 155, 186, 234, 235
left
side 126f
upper 198
lower 82, 177
mid 109, 110f
middle upper 198
point 199
mid-quadrant of 206
right side of 109, 272f
scarred 95
Abdominal access 277
Abdominal bulging 251
Abdominal cavity 53, 57, 169f, 233, 297
Abdominal distension 288
Abdominal entry, complications related to 278
Abdominal pathology, left upper 42
Abdominal pressure 243
Abdominal surface 33f
Abdominal surgeries 63
Abdominal wall 57, 69, 71, 90, 146f, 226, 229f
adhesions 44f
anatomy 41, 233
anterior 3, 5f, 43, 48f, 69, 72f, 126f, 142, 224, 245f, 251, 279
anticipated thickness of 91f
braced 22
fascia, anterior 243
hematoma 279
incision 143
lateral 228
layer 143
of anterior 225f
sequencing 29f, 30f
neoplasms 252
risk for anterior 65
surgical anatomy of anterior 3
vessels 278
Abdominal-pelvic masses, large 50
Abscess 252
Absorbable sutures 285, 286
Adherent peritoneum 65
Adhesiolysis 195f
avoid extra 251
Adhesions
abdominal 109
amount of 130
entry free of 49f
free of 102
right side 129f
type of 109
Adipose and membranous tissues 224
Advanced gynecologic malignancy 45
Air embolism 283
Allis forceps 58
Anatomical landmark 42
Ancillary ports 32, 34
subsequent 21
Ancillary trocar placement 21
Anemia 243
Anesthesia, general 64
Annula design 21
Anti-Koch–s treatment 194
Aorta 152, 277
abdominal 47
distal 71
Aortic bifurcation 50, 6971, 153
Appendectomy 255
Appendicitis 254
subacute 111
Appendicular artery dissected 262f
Appendix
base of 262f
being cut 263f
visualized 262f
Archimedes’ principle 19
Arcus tendineus 221
fascia 212, 213f215f
right side 209f
Arrhythmias, signs of 152
Arteria corona mortis 7
Arterial injury 278
Arterial supply 4
Artery
forceps 59f
superficial 5f
Arthroscopy 12
Asherman–s syndrome 186
Atraumatic grasper 295
Azygos venous system 8
B
Back pain 114
Backache 114
Barb sutures 201
Bariatric surgeries 254
Betadine solution 80f
Bifurcation–s location 70
Bipolar cautery, incision by 178f
Bladder 278
injury 282, 285, 285f
neck 212
Blind port entry 102, 125, 248
Blind puncture 143
Blind steps 235
Blind umbilical
port insertion 107
trocar 103
Blood
pressure, measuring 152
vessels
injuries of 278
major 69, 87
Body maneuvers 116
Body mass index 87, 142, 151
increases 50
normal 10
Bony iliopectineal ligament 216
Bowel 79f, 126f, 251, 281
adherent 48f
adhesions 102, 108
herniation
risk of 156
subsequent 156
infections, types of 129
injury 248, 281, 281f
complication of 64
evidence of 54
incidence of 128
laceration 281f
perforation, risk of 289
peristalsis 30
segmental resection of 271
small 277
Bronchoscopy 12
Bruce patsner 45
Burch colposuspension 207
procedure 271
Burch sutures completed, four 211f
Burn
scars, injuries of 129
small scars of 129
C
Caliber microlaparoscopes 17
Camera port 168
insertion 170f
Camper–s fascia 4
Cannula 13f, 143
bladeless 17
tip 30
diameter 22
distal tip 30
entry 35
removal 35
rotation 19
stem 25
systems 16
tract 35
with cone 16f
Carbon dioxide retention 283
Cardiac arrhythmia 283
Cardiopulmonary status 152
Caseoma, multiple 193f
Caseous material drained, copious amount of 193f
Catastrophic complications 87
Catastrophic injury 107
Catecholamine release, excessive 155
Cervical
fibroid, huge 166f
isthmus 216
spondylitis 114
Cervix 216
junction of 221
Cesarean sections, previous 125
Chevron incision 79, 80f, 200f, 271, 272f
Kocher–s 255
Chicken wing scapula 114
Cholecystectomy 127
Chopstick effect 120
Chronic pain 251
Cochrane database 55
Colectomy, total 254
Colon 277
distal 285
injury 281
from primary port insertion 45
Colpotomy 160f, 180f
closure 181f
completed 98f
Common iliac
artery 47
vein, left 70
Cooper–s ligament 207, 210f, 216, 217f, 218f
exposure of 208f
Costal margin 42
Cough 156
Crohn–s disease 129, 254
Crystal tip, distal 24
Curtis syndrome 191
Cutaneous vessels 5f
Cyst
large 177
puncture of 177
simple 177
Cystectomies 125
Cystocele, central 212
Cystoscopy 265f
D
Da Vinci machine 50
Deep circumflex iliac artery, anatomy of 10
Deep crural arch 9
Deep retroperitoneal vessels 111
Dense adhesions 267f
Dense omental adhesions 192f
Dermoid cyst 177, 178f
huge 179f
Deschamps needle 289
Diabetes 243
Diaphragmatic hernia repair 255
Disposable bladed access 14
Dissection completed 260f
Distending gas 13
Drop test, check of 168
Dysgerminomas 177
E
Ease of entry 168
Electrocardiogram 152
Emphysema, surgical 233
Encasing outer sheath 13f
Encourage early ambulation 162
Encysted collection 188f, 194
Endobag 180f
appendix extracted in 263f
cyst in 180f
enucleated 179f
specimen removed in 258f
Endometriotic cyst, large 166f
Endometriotic nodule, big 265f
Endoscopic leak test, confirmatory 258f
Endoscopic surgery 47
use of 47
Endoscopic techniques 15, 198
Endoscopic threaded imaging port 19f, 128
Endoscopists’ career 35
Endoscopy 12, 47
EndoTIP 27
ancillary access with 31
cannula 27f, 28f, 33f
application, closed 29f
open application of 30f
layered access with 19f
open laparoscopic access with 29
visual cannula 32
entry path 32f
removal 34f
Endotracheal intubation 64
Enhance visualization, techniques to 155
Entry point, established alternate 39
Entry-related complications 277
Epigastric artery
bleed, acute inferior 279f
deep inferior 6, 7f
inferior 4, 31
superficial inferior 4
superior 4, 6
types of deep inferior 7f
vessels, inferior 278
Epigastric vessel 31
inferior 31, 278
Epigastrium 127
Ergonomic port 116
Ethicon endo-surgery 16f, 57, 60
Extraperitoneal fat 9
Extraperitoneal gas, needle aspiration of 284f
Extraperitoneal insufflation 283, 284f
Extrocation 294, 297
Eyes, burning 114
F
Falciform ligament 3, 170f
Fallopian tubes, blocked 186
Fascia 65
abdominal 143
defect 60
superficial 4, 224
underlying 225
Fascial closure 243
advantage of primary 249
device 289
primary 248
techniques 289
Fascial level, close port sites at 156
Fascial wound, smaller 34
Fibroid
large 166f
uterus 95f
big size 173f
Fibrous cicatrix umbilicus 3
Fibrous portion 221
Final port placement 92f, 105f, 135f, 171f
for surgery 52f
First blind port umbilical entry, hazards of 69
First suture completed 211f
First-generation
insufflated access methods 21
noninsufflated access methods 24
Fitz-Hugh-Curtis syndrome 191
Flabby abdomen 93, 94f
veress needle in 94f
Foley–s bulb 212
Fundal wrap, suturing of 261f
Fundoplication 254
G
Gallbladder 191f, 193
surgery
open 127, 271f
previous 78
Gangrenous bowel, reduction of 289
Gangrenous gut 289
Gas tubing after syringe test, attachment of 157f
Gasless laparoscopy 16, 25
Gastric injury, inadvertent 32
Gastric mass 42
Gastric surgery 143
Gastrointestinal
injury 282
organs 278
tract 69, 87
Gastrolysis 256f
Gastropancreatic masses 143, 236
abdominal 82
Gastroscopy, unintended 78
Genital tuberculosis 125, 186, 194
diagnosis of 186
poses 186
rise of 77
Genitofemoral nerve 269f
Genitourinary system 278
Gynecologic conditions 277
Gynecologic malignancies, treatment of 47
Gynecologic surgery 234, 285
Gynecological endoscopy procedures 47
H
Hand muscle injury 114
Hand wrist muscles 28
Harm–s way 22
Harmonic ace 202f, 208f, 256f, 259f
adhesiolysis with 246f
Hasson port, reinsertion of 55
Hasson technique, modified 57
Hasson–s blunt tip trocar 54, 55f
Hasson–s open
entry technique 53
entry trocar 16f
laparoscopy port 54
method 61
technique 127
Hasson–s technique 55
Hematogenous 290
Hematoma 56, 252, 279
expansion, signs of 279
minor 143
Hemorrhage 249
abdominal 291
Hemostasis 201
Hemotoma, abdominal 291
Hepatic surgery, previous 200f
Hepatomegaly 42
Hernia 289, 292
complex incisional 243
defect 246f, 252, 259f
diagnose occult 252
incarcerated 252
incisional 243, 255
pathogenesis of 288
port-site 286
reduction of 289
repair 244, 248
primary 243
sac 248
safe entry in 248
surgery, basic 249
Hydatid cyst removal 272f
Hydrosalpinx 187f
dilated 187f
Hypertension 152
portal 8, 143
Hypertrophy, ventricular 152
Hypoproteinemia 243
Hysteroscopy 12
I
Iatrogenic enterotomy 249
Ileocecal Koch–s 111
Ileopectineal ligament 216
Iliac artery 277
deep circumflex 5
external 4
right common 71
superficial circumflex 4
Iliac crest 3, 69
Iliac retroperitoneal vein 277
Iliac spine, anterior superior 4, 50, 83, 87, 88, 88f, 89f, 105, 110f, 116, 131, 144, 167, 201, 225f, 236, 254
Iliac vessels, external 31, 216
Iliopectineal ligament 216, 218f220f
left-sided 217f
right-sided 218f
Immunosuppression 243, 290
Incision
longitudinal 58f
types of 82
Incisional hernia, repair of 243, 249, 250t
Infection, operation site 288
Infectious disease, history of 77
Infectious pathologies 125
Infertility 186
primary 144f
Inflammatory masses 292
Infundibulopelvic ligament, bilateral 159f
Inguinal canal, posterior wall of 6
Inguinal hernia surgery 9
Inguinal ligament 3, 5
Injury, types of 53
Instrument
access 13
designers of 116
irrespective of 20
Insufflation 28
pressure 94
Intercostal muscles 8
space, left ninth 63
Interfoveolar ligament 9
Intestinal injuries 69
Intestinal obstruction 272f
with colostomy 189f
Intestinal pathology 127
Intestinal tuberculosis 254
Intra-abdominal
adhesions 64, 65, 236
contents 72
gas 283
lesions 64
organs 63
pressure 23
test 94
Intraoperative displacement 14
Intraperitoneal dense adhesions 264f
Intraperitoneal needle placement 23
Intraperitoneal placement 65
Intraperitoneal pressure 23
Ipsilateral port 117f
placement 117f
Ischemia 152
Ischial spine 212
Isoechoic mass, solid 186, 187f
J
Jain point 50, 51f, 73f, 83, 87, 89f, 94, 102104, 103f, 108f, 110f, 130, 142, 143, 148f, 154f, 167, 177, 194, 199, 206, 224, 226, 227f, 232, 252, 255
abdominal wall at 228f
advantage of 82
anatomic location of 201f
anatomy of 111
application of 123
direct
trocar entry at 234, 235, 237f
vision through 231f
distance of 111
entry 104, 162
benefits of 231
entry technique 90, 144, 154
complications encountered in 291
ergonomic 114, 118f
placement of 118f
evolution of 102
finger
guide at 227f
pointing at 90f, 131f
free 107f
in genital tuberculosis 186
in obese patients 151
in practice of general surgery 241, 254
in upper abdomen scar 198
inserting Veress needle at 132f
introduction of 85
level of 224
mirror image of 168
paraumbilical port 162
port 49f, 92f, 109f, 131f, 171f, 173f, 243
converts 119f
ipsilateral working with 232f
vision of 51f, 197
primary port at 169f
rationale of 107, 193
role of 125
surface marking of 82f, 83, 99, 103f, 126f, 225f
surgical blade at 132f
telescope at 147f, 231f
to left lower port 119f
trocar 238f
using 107
Veress
insertion at 169f
needle at 190f
vision of 95
with stretched skin 145f
Jain port 248
Joint pain, hand finger 114
K
Koch–s abdomen 255, 264
Koch–s, appendicitis 129
Kocher incision, big 127
Kocher–s clamps 54, 58
Kocher–s incision 78, 271, 271f
L
Lactate fluid 294
Laparoscopes intense 28
Laparoscopic access 279
injury 20
instrument 15
conventional first-generation 13f
second generation 17
techniques 20t
with endotip, closed 27
Laparoscopic complications 111
Laparoscopic entry 12, 172, 186, 191, 234
in large pelvic masses 164
injuries 69
incidence of 69
risk for 142
sites 63
technique of 188
time of 142
with big masses 177
with large uterine size 183
Laparoscopic hernia repair 243, 278
Laparoscopic hysterectomy, total 95f
Laparoscopic injuries 57
Laparoscopic instruments 14
Laparoscopic mesh hernia repair 130
Laparoscopic oncologic surgery 47
Laparoscopic port 35
Laparoscopic procedure 142, 216, 278
Laparoscopic shoulder 114
Laparoscopic surgery 44, 69, 72, 102, 151, 153, 277
abdominal access for 281
equipment 73
evolution of 224
field of 41
major 50
step in 53, 69
Laparoscopic techniques 292
Laparoscopic trocar 65
Laparoscopic umbilical entry 48
Laparoscopic ventral hernia repair 244
Laparoscopy 12, 114, 151, 207, 234, 277, 294
closed 55
during 70
entry safer 107
open 55, 56
operative 109
practitioners of 116
surgery, regular 57
Laparotomy 152, 285
advantages over 234
exploratory 271
infraumbilical midline 72f
instruments, conventional 26
midline 72
performed 290
previous 272f
Lax abdomen 228
Lee-Huang point 4750, 51f, 82, 103f, 127, 134f, 198, 199, 237
advantages 199
disadvantages 199
insertion 49, 236
limitations 199
Lee-Huang technique 234
Left umbilical vein, remnant of 3
Left upper quadrant 43, 43f, 198
Ligament
coagulation and cutting of round 96f, 97f
open up broad 96f
round 216
Ligamentum teres hepatis 3
Linea alba 8
Liver 191f, 193, 278, 281
bed suture 282f
Low transverse incisions 87
Lumbar quadrant, left 224
Lumbar vertebrae 69
Lymphoid nodules 109
Lymphoid tissue 254
M
Malignant cells 33
Malnutrition 243
Mantoux test, positive 144f
Mass
big cystic 103
entry
in patients with large 164
technique devised for very large 168
extralarge 172
large 103, 165f, 292
removal of large 173f
technique in large 168
upper abdominal 143
very large 165f
with transverse scar, large 182f
with vertical scar, large 183f
Mayo scissors 25
Mediastinal emphysema 283
Medical treatment for Koch–s 197
Medicine, practice of 53
Membranous layer 4
Mesenteric artery, inferior 47
Mesenteric vessel, secondary branches of 277
Mesh fixed with tacker 247f
Mesh hernia repair 139
previous 245
Mesh infection 251
Mesh repair 248, 249
Micro bipolar forceps 65
Microlaparoscopy optical veress access system 18f
Mid-line incisions 128
Military position 153
Minimally invasive surgery 41, 87, 114
Monopolar hook 160f
Morbid obesity 33
Morbidly obese patients 154f
Multiple bowel loops stuck 108f, 192f
Multiple defects 252
Multiple previous scars 103
Muscle 8, 65
abdominal 6f, 49
tone 145
Musculoskeletal ailments, severe 114
Mycobacterium tuberculosis 186
Myoma 173f, 201, 202f, 203f
after enucleation of 175f
bed 203f
bed sutured 177f
final appearance of 205f
big 165f, 201
deep posterior wall 202f
enucleation of 175f, 203f
large 172, 172f, 177
number of 172
size of 172
using harmonic ace, incision over 174f
white 201
Myomectomy 125, 172
easy 172
N
Nasogastric tube 32, 42, 282
Natural orifice transluminal endoscopic surgery 12
Neck pain 114
Nephrectomy 255
Nerve injury 283
Ninth intercostal space 65
surface marking of 64f
Nonabsorbable suture 219f, 220f
Nonumbilical entry 57, 162
Nonumbilical insufflation needle entry 65
Nonumbilical midline entry 57
Nonumbilical port 104, 110
primary 194
Nonumbilical veress needle insertion 64
Number surgical blade 90f
Nutrition, poor 288
O
Obese laparoscopy 153
Obesity 288, 292
Oblique aponeurosis, external 133
Oblique muscle, internal 133
Obstructive pulmonary disease 152
Omental adhesion 102, 107, 126
at umbilicus 76f
Omental emphysema 108, 109
Omentum adherent 245f
Open surgery 164
Open technique, advantages of 143
Open-entry technique 57
disadvantages of 61
Optical access 15
Optical port entry, primary 233
Optical veress
entry system 17
microlaparoscope 32
Optimal access, position for 153
Oral pyridium 288f
Orogastric tube 64, 282
Ovarian cysts 172, 177
entry in patients with 172
large 167f
Ovarian cystectomy, steps of 177
Ovarian fibromas 172
Ovarian fossa 286
Ovarian ligament, coagulation and cutting of 95f
Oxidized regenerated cellulose 250
P
Pain, postoperative 283
Palmer–s entry 44
Palmer–s point 41, 44, 48, 49, 57, 63, 76, 78, 8183, 89, 102, 103f, 116, 127, 128, 130f, 134f, 143, 198, 201, 234, 236, 237, 245
adhesion at 80f, 200f
advantages 198
contraindications of 76
disadvantages 198
entry 41, 43f, 44f, 76
entry via 44
finger pointing at 77f, 80f
landmark of 42f
limitations of 76, 198
lying 200f
site for 43f
surface anatomy of 78f
telescope at 77f
Palmer–s technique 149, 282
Pancreatic mass 42
Para-aortic lymphadenectomy 48
Paramedian incision 128
Paraovarian cyst 177
Pararectal space, left sided medial 136f
Paraumbilical region, left 89, 89f, 109, 110f, 144
Paraurethral tissue, elevating 209f
Paravaginal defect repair 212
sutures 212
Paravaginal suture 214f
Paravaginal tissue 209f, 215f
Peanut sponges 27
Pectopexy 216
for posterior compartment, part of 223
Pelvic anatomy 232f, 286
Pelvic brim 109
dissection at left 136f
level of 224
right 137f
Pelvic cavity, picture of 158f
Pelvic dissection 286
Pelvic examination, normal 63
Pelvic floor
defects 207
repair 207
reparative surgery 207
Pelvic mass 73
abdominal 49
large 73, 95, 164, 167, 183, 184
Pelvic-abdominal organs 22
Pelvis 186, 196f
and upper abdomen 134
appearance of 135f, 195f
female 164
lower 109
right side of 137f
surgeries deep in 207
Penetrating injury 56
Performance shaping factors 26
Peripheral intravenous access fails 153
Peripheral vascular disease 152
Peritoneal adhesions 33
Peritoneal cavity 15, 16, 33f, 62f, 279
Peritoneal defect 212
Peritoneal entry 31
Peritoneal insufflation 49
Peritoneal membrane 30
Peritoneal sheath, posterior 61f
Peritoneal signs, absence of 282
Peritoneal space 235
Peritoneum
closure 211f, 216f, 220f
cutting uterovesical fold of 97f
Periumbilical adhesions 43f, 48, 107
Periumbilical region 73, 73f
Peyer–s patches 109, 254
Pfannenstiel incision, lower 128, 139
Physician insurers association 22
Pneumatic boots 153
Pneumoinsufflator 60
Pneumoperitoneum 42, 53, 54, 62, 69, 143, 155, 168, 234, 238f, 283, 291f, 294
after achieving 155
complications related to 283
creation of 41
establishment of 63
needle 63, 64, 282
Pneumothorax 283
Polypropylene 250
Polytetrafluoroethylene, expanded 250
Ports
complication-performance shaping factors, etiology of 26f
configuration, suprapubic 238f
dynamics during laparoscopy 20
entry, point of primary 57
first blind 99, 116
in situ 157f
insertion 27
left-sided 207
lower 92f, 118f
operating 279
paraumbilical, right side 171f
placed 43
placement 259f
contralateral 115f
initial 248
plugs 289
position 43f
external view of 245f, 256f, 261f
removal of 289
importance of 33
site metastasis 290
upper and lower 116
upper working 171f
working, contralateral 115f
Portal hypertension, signs of 42
Pouch of Douglas 196f
Preinsufflated laparoscopy 31
Preperitoneal insufflation 108, 228
Preperitoneal placement 109
Previous surgery 292
Primary entry techniques 35
Primary port 21
entry 51f, 69
insertion 21
placement 111
Primary trocar 32, 48, 69, 72
entry 25, 230f
insertion 47, 48, 53
Prominent sacral promontory 71
Prosthetic materials 243
Psoas
hitch suture 269f, 270f
muscle 269f
Pubic symphysis 9
Pubovesical fascia 216
Pubovesicocervical fascia 223
plication 217f
Pudendal artery, superficial external 4
Pulmonary abnormalities 152
Pulmonary complications, postoperative 156
Pulmonary compromise 155
Pus
collected, copious amount of 196f
coming, copious amount of 195f
Pyeloplasty 255
Pyramidal trocar wounds 19
R
Rectal surgery 285
Rectovaginal fascia 207, 223
Rectovaginal nodule 138f, 139f
excised 138f
Rectovaginal space 138f
Rectus abdominis 6
Rectus fascia, anterior 25
Rectus sheath
entry 60f
excised 60f
formation of 6f
incision on 59f
Remain centrifugal 251f
Renal surgeries 255
Reproducibility, advantage of 62
Retroperitoneal bleeding 184
Retroperitoneal hematoma 71, 71f, 279, 280f
Retroperitoneal operations 27
Retroperitoneal vascular injury, major 70
Retroperitoneal vessel 73, 107
injury 102, 108
injury, risk of major 146
Rib, lower border of 127
Richter–s hernia 286, 288, 289, 294
Robot-assisted radical prostatectomy 45
Robotic surgery 12
Rooftop incision 200f
Room-air streams 31
S
Sacral promontory 111, 143
Safe entry port 162
Safe laparoscopic entry 142
Saline
aspiration
and infusion test 229f
test 132f
drop test 146f
infusion technique, novel 127
Scar
abdominal 143
big vertical 81f
midline vertical 111
multiple 183f
on abdomen, multiple 125f
upper abdominal 206
vertical 89f, 182f
paraumbilical 177
Scarpa–s fascia 4
Septicemia 189f
after previous laparotomy 190f
previous 82
Seroma 250
Sheathed laparoscope 28f
Shoulder
abduction of 114
and elbows 116
pain 297
Sigmoid colon adheres 129
Skin 65
changes 152
dystocia 22
incision 22
generous 30
generous subumbilical 27
site for 54
retractors 59f
Sleep apnea 152
Sleeve gastrectomy 255
Small intestine adherent 72f
Smoking 152
Solid organ injury 235
Space of Retzius 208f, 212, 212f, 267f
complete exposure of 213f
entry into 268f
repairs 207
space 207
Spermatic fascia, internal 9
Spleen 281
and kidney 224
enlargement of 81f
Splenic enlargement 79
Splenic surgery 143
Splenomegaly 42
Stab wound 64
Starting enucleation 179f
Stomach 78, 281
decompression 64
Stone surgeries 255
Strain 152
Stress exhaustion 114
Stress-free working 116
Subcostal margin 76
inferior 65
Subcutaneous emphysema 155, 283
Subumbilical adhesions, high risk for 45
Supraumbilical region 8
Surgeon–s index finger 64
Surgery, course of 105
Surgical indications 125
Surgical site infection 289
Surgical technique 89
Suture
carrier 289
ligation 279
material selection 243
passed through bladder 270f
T
Telescope
port 148f
trocar 297
stopper 19, 19f, 21f
Tendon, intermediate 8
Tenosynovitis 114
Terminal ileum 109, 110
Thoracic region 8
Thoracoscopy 12
Thromboprophylaxis 162
Tissue
cannula interface 128
dissection and hemostasis, complications related to 283
injury 35
interaction 286
layers, abdominal 13
Transfascial sutures 247f
Transumbilical insufflation, angle of needle insertion for 143
Transversalis fascia 9, 225
Transverse incision given 174f
Transverse rectus abdominis myocutaneous 6
Transverses abdominis muscle 5, 133, 225
aponeurosis 93
Trapezius muscles 116
Traumatic intestinal injuries 282
Trendelenburg position 41, 153
Trocar 15, 153
advancing primary 235
bladed blind 26
blunt 54
central 13f
conical-tip 278
disposable 62f
entry technique 235
hernia 286
inserted at Jain point 91f, 104f, 133f, 190f
insertion 63
placement of 21, 61, 152, 226
punctures 282
secondary 278
sharp 16
system 17
Trocar and cannula 231f
conventional 23
disposable radially dilating 18f
first generation 35
tips, different 14f
Trocar-site hernia 288
Tubercle nodules 264f
Tubercular cold abscess 194
Tubercular pyosalpinx 195f
Tuberculosis 82, 194
abdominogenital 188
abdominopelvic 77
adhesions of 193
Tubomass 148f
Tubo-ovarian
ligament, coagulation and cutting of 97f
mass 149f, 188f
bilateral 144f
U
Ulcerations 152
Umbilical adhesions 24, 76
Umbilical aortic bifurcation 70
Umbilical entry
hazardous 107
point 142
Umbilical hernia 56, 143, 255
physiological 3
Umbilical insufflation fails 63, 65
Umbilical ligament, median 3
Umbilical port 76
conventional 164
Umbilical skin incision 22
Umbilical trocar insertion 56
Umbilicus 3, 42f, 50, 69, 70, 92f, 225f
anatomy of 70f
level of 88, 144, 207, 226f
lie 103
to Jain point 119f
Unfamiliar territory 82
Upper abdomen 47, 48, 82, 109, 186, 193, 201
adhesions 199
incision 128, 199
laparotomy cases 199
scars 79f
Upper arm muscles 20
Urachus, remnant of 3
Ureter 268f
dilated 267f
fish mouth, cut end of 270f
right 137f
stricture end of 269f
Ureteral damage 286
Ureteral injury 285
Ureteric reimplantation 255, 271f
Ureteric stent 265f
Urinary retention, postoperative 212
Urinary tract surgeries, upper 255
Urogenital diaphragm 207
Urologic surgery 285
Uterine artery
bilateral 160f
skeletonized 96f
Uterine enlargement 183
Uterosacral ligament 138f, 221, 223
left side 222f
plication of 221, 221f, 223f
right 222f
right side 221f
Uterovaginal prolapse, grade IV 217
Uterus
after injected diluted vasopressin 174f
large 95
obscuring 156f
surface of 148f
tubes 195f
V
Vaginal apex 218f
Vaginal vault, closure of 98f
Vascular injury 32, 50, 278, 279
rates of 235
Vault closure completed 99f
Vena cava, inferior 8, 47, 278
Venous
drainage 8
injury 278, 283
Ventral hernia 34, 243, 244, 255
repair of 243, 249, 250t, 252
Veress injury, catastrophic complications of 146
Veress insertion 73, 182f, 184f
sites for 47
Veress intraperitoneal pressure 155, 230f
low initial 168
Veress needle 22, 23, 32, 41, 43, 65, 72, 91f, 93f, 108, 133f, 142, 143, 153155, 227f, 232, 236
direction of 104f
entry 51f, 142, 144
proceeding for 65
flaying medially, chance of 90
insertion 65, 71, 71f, 99, 145, 154f, 224, 255
steps of 226
layer by layer 93
placement of 229f
single prick with 93
with finger guard, holding 91f
Veress placement 21
Veress tubing 23
Veress type needle 17
Vesicovaginal fistula repair 255
Vessel 104
Vessel injury
complication of 64
major 149
risk of major 107f
Vicryl
suture 58
upper layer closed with 176f
Viscera 104
abdominal 23
Visceral injury 30, 50, 235, 281
Vision
central 48
opened under 61f
under direct 49
Visual access 15
cannula
reusable 19f
system, bladeless 20
method, second-generation 26
systems 35
Visual cannula 2931
Visual entry instruments 24
Visual guidance, under 50
Visual instrument, bladeless 35
Visual laparoscopic access 33
Visual trocar and cannula, disposable 17f
Vitellointestinal duct 3
V-loc suture 204f
completed with 176f
staple line imbricated with 257f
suturing starting using 175f
V-suture technique 161f
Vulvar edema 291
W
Waist circumference 152
Wertheim–s hysterectomy 254
Whipple–s procedure 254
Wound
abdominal 24
contamination 56
infection 289
minor 143
×
Chapter Notes

Save Clear


_FM_1Non-Umbilical Laparoscopic Entry Ports_FM_2
Vardhman Super Specialty Hospital, Muzaffarnagar, Uttar Pradesh, India
_FM_3Non-Umbilical Laparoscopic Entry Ports
Nutan Jain MS Director Department of Obstetrics and Gynecology Vardhman Super Specialty Hospital Muzaffarnagar, Uttar Pradesh, India Forewords Harry Reich Ceana Nezhat Pawanindra Lal Parveen Bhatia Sven Becker
_FM_4
Jaypee Brothers Medical Publishers (P) Ltd.
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Overseas Office
JP Medical Ltd
83 Victoria Street, London
SW1H 0HW (UK)
Phone: +44 20 3170 8910
Fax: +44 (0)20 3008 6180
© 2020, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
Non-Umbilical Laparoscopic Entry Ports
First Edition: 2020
9789389776454
Printed at
_FM_5Dedication
This book is dedicated to all my worthy endoscopy fellows and trainees who contributed by trying and learning the “Jain point” entry in different types of challenging situations and thereby giving us insights to further improving and improvising the technique and bringing it up to its present methodology of almost flawless insertion of the first blind nonumbilicalentry port._FM_6
_FM_7Contributors _FM_11Foreword
Being asked to write a forward is always an honor but to do so for Dr Nutan Jain who I have greatly admired for many years is surely a pleasure. This book describes the rationale for Jain–s point and explains it very well. I agree that perforation of large vessels would be extremely rare at this point. Usually I am more concerned about perforation of intestine in adhesion cases and thus I go higher, in the ninth intercostal space, as this area has served me well since 1990. But I must commend Dr Jain for presenting a technique much easier and safer for the average laparoscopic surgeon. I never liked Palmer–s point as I never knew what I could get into there. I like the concept that I can feel the ribs for my point and that the anterior-superior iliac spine is readily available for Dr Jain–s point. Actually it seems that Dr Jain‘s point is the lowest of the three points and may be best for routine use.
Harry Reich Retired
Honorary Member, AAGL
Past President, ISGE, SLS
Southern Ocean Medical Center, Hackensack—Meridian Health Center
New Jersey, USA_FM_12
_FM_13Foreword
Dr Nutan Jain has taken on the role of international educator and is revered as one of the most distinguished surgeons in the minimally invasive arena. Her focus on teaching is admirable. This book provides another opportunity for Dr Jain to share her innovative expertise on laparoscopic surgery with colleagues.
Video Assisted Laparoscopic Surgery, with and without robotic assistance, has become the most innovative and effective technique for performing intra-abdominal procedures. As advancements in technology and operative technique continue to develop, the basic principles of laparoscopic surgery remain pivotal when considering patient safety and outcomes. While instrument choice, energy source, and knowledge of pelvic anatomy are of utmost importance, abdominal entry remains the most critical step in laparoscopic surgery. To date, a single, ideal method of entry for all patients has yet to be described. The best approach is truly individualized, and must consider the patient–s risk of prior adhesion formation, the possibility of distorted anatomy, size and contour of the pelvic organs, the patient–s body habitus, and the planned surgical approach.
Umbilical port placement is the conventional method used to gain access to the abdominal cavity, and approaches include direct entry, the Veress needle technique, the open “Hassan” technique, or visual entry using an optical trocar. Complications include failed entry, bowel injury, inadequate exposure, vascular injury, and extraperitoneal insufflation. Several alternatives to blind port placement have been used when umbilical entry is deemed hazardous. These include Palmer–s point, Left ninth intercostal space, and vaginal or uterine entry by way of natural orifice transluminal endoscopic surgery (NOTES). Perioperative ultrasonography has also been utilized to map out safe entry sites using periumbilical ultrasound-guided saline infusion (PUGSI). I agree “as the prevalence of surgical management increases, alternative entry sites will be necessary”. Jain point is a novel entry site that has not been previously reported.
This book provides a brief overview of relevant abdominal anatomy and previously described abdominal entry techniques, while focusing more on the utility and application of new trocar entry sites. This detailed composition is a must-read for both aspiring laparoscopists, and master surgeons, alike.
Ceana Nezhat MD FACS FACOG
Fellowship Director, Nezhat Medical Center
Medical Director of Training & Education and
Director of Minimally Invasive Surgery & Robotics,
Northside Hospital, Atlanta Georgia
Adjunct Professor of Gynecology and Obstetrics, Emory University
Past President, Society of Reproductive Surgeons
Past President, American Association of Gynecologic Laparoscopists
Editor-in-Chief, Atlanta Medicine_FM_14
_FM_15Foreword
It gives me a great pleasure to write the foreword to the book entitled “Non-Umbilical Laparoscopic Entry Ports” by a pioneer laparoscopic gynecologist Dr Nutan Jain. In this book, which is itself, a rarity, as there are very limited books on port access in laparoscopic surgery, Dr Jain has taken the readers through the surgical anatomy of the abdominal wall and then discussed the existing alternate entry points that are already established. She then takes the readers through the challenges posed in entry especially in a previously scarred abdomen. The highlight of the book is the description of the “Jain point” which she has described after thousands of cases done using the same and the chapters related to these are authored by herself with detailed description of the evolution, rationale and the ergonomics of this point. This point was described her in her publication of 2016 in the Journal of Human Reproductive Sciences as an original article where Dr Jain described the point in 624 patients operated from 2010 to 2014. The Jain point has been described to be located in the left paraumbilical region, in a straight line drawn vertically upward from a point 2.5 cm medial and 10 cm above the anterior superior iliac spine.
Having described the safe technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube which was published in Surgical Endoscopy in 2002 and later on the follow-up original article in 2012 on 6000 cases using the same technique, I am very happy to say that an Indian gynecologist has used her vast experience to help the surgical community by describing the Jain point for closed entry and reported it to be as safe as the Palmer–s point. The advantage being that while placing it in the lower abdomen and laterally, this point becomes one of the ports for surgical procedure as well.
I am sure this publication will find favor with all practicing gynecologist and surgeons and will form a reference for all those who wish to acquire knowledge about open and closed access techniques. I congratulate, Dr Nutan Jain for a publication that has the potential to bring Indian surgery to an international pedestal.
Pawanindra Lal
MS DNB FIMSA FCLS FRCSEd FRCSGlasg FRCSEng FACS FAMS
Consultant Laparoscopic Gastrointestinal, Oncology and Bariatric Surgeon
Chairman, Division of Minimal Access Surgery
Head of Clinical Skills Centre
Editor-in-Chief, MAMC Journal of Medical Sciences
Vice-President, International College of Laparoscopic Surgeons
EC Member, Association of Surgeons of India
President, ASI Delhi Chapter
President Elect, Indian Hernia Society
Director Professor and Head
Department of Surgery
Maulana Azad Medical College (University of Delhi) and
Associated Lok Nayak Hospital
New Delhi, India_FM_16
_FM_17Foreword
“It is puncture itself that causes risk” was the bold statement by Dr Hans Jacobaeus (1879–1937), Inventor of Laparoscopy and Thoracoscopy in 1910. This century has made the surgeons, gynecologist, urologist, cardiac, ENT surgeon, etc. minimal access surgeons—the cerebral laborers rather than the manual laborers. Still, we have not reached “Zero harm goal” level surgeons.
In specific situations like battered abdomen with previous abdominal surgeries scars, morbid obesity, complex ventral hernias, organomegaly, etc, the surgeon has to pray before entering into the pandora box to be safe. We strongly believe on “There is safety in more safety.” Safety is the avoidance of a negative outcome; quality is the achievement of a positive outcome. To enter into the abdomen, umbilicus and nonumbilicus points have been described by both nonoptical and optical entries.
I must compliment, Dr Nutan Jain, the thinking surgeon (gynecologist), to write this book on a single theme-safety in abdominal wall access. ‘Jain point’ re-emphasizes the importance of relatively avascular horizontal line of umbilicus and the fixed bony landmark (anterior-superior iliac spine). Surgeon is always advised to think of all the three muscle layers of abdominal wall, i.e. external oblique, internal oblique and transversus abdominis at the time of blind Veress needle entry. The chances of injury to the viscera and vessels (including inferior epigastric vessels) are further reduced by this point entry.
Happy to note that one chapter has been dedicated to the complications of entry and exits. To be safe, “all entries and all exits must be shown by the camera person.”
Dr Nutan Jain–s immense experience, innovative thoughts and sharing of the knowledge in this color atlas is highly commendable. “Knowledge shared is Knowledge gained.”
Parveen Bhatia
MS FRCS(Eng) FICS FIAGES(Hon) FMAS FIMSA FAIS FALS FCLS
Senior Consultant Laparoscopic, Bariatric and Robotic Surgeon
Institute of Minimal Access, Metabolic and Bariatric Surgery (IMAS)
Institute of Robotic Surgery (IRS)
Sir Ganga Ram Hospital, New Delhi, India Medical Director
Bhatia Global Hospital and Endosurgery Institute, New Delhi
Editorial Board, Journal of Minimal Access Surgery
Author of 3 books: Laparoscopic Hernia Repair: A Step-by-Step Approach; Art of Endosuturing: A Step-by-Step Approach; Comprehensive Laparoscopic Surgery_FM_18
_FM_19Foreword
Laparoscopy has become the most common approach to gynecologic surgery.
Hysterectomy, myomectomy, treatment of ovarian cysts, management of ectopic pregnancies, surgery for endometriosis, adhesiolysis, fertility-surgery and management of oncologic disease have all become standardized as minimally invasive surgeries.
While the command of the actual surgery is central to the art and science of laparoscopy, obtaining safe access to the abdominal cavity remains the first step of this surgery and is particularly for the less experiences surgeon—the most dangerous and complicated part of the procedure.
In this wonderful book, the focus is exactly on different laparoscopic entry-techniques. Dr Nutan Jain has to be commended for her efforts to thorougly explain the different approaches, their histories, advantages and disadvantages. And also to introduce a new safe portal for laparoscopic entry, the Jain point, which could be feasible in many challenging situations.
This book is an excellent reference for those eager to learn about this basic part of everyday laparoscopy but also for the experienced surgeons as a review of the available options of entry in difficult situations.
Sven Becker MD PhD
Director, Frankfurt University Women–s Hospital
Goethe University
Frankfurt, Germany_FM_20
_FM_21Preface
Laparoscopic entry has always been a daunting task, and, even, the most experienced laparoscopists would admit they still feel a relief after seeing safe entry in the face of a challenging case. Previous surgery is the first situation which alarms the surgeon to the possibility of periumbilical adhesions, rendering umbilicus a hazardous site to make entry. Palmer–s point has been the trusted site by general surgeons, urologists and gynecologists for several decades, since the inception of operative laparoscopy. It has all the merits and few contraindications. But the contraindications such as, upper abdominal large gastropancreatic masses, upper abdominal previous surgery scars as the open Kocher–s incision, Chevron incision, enlarged spleen due to portal hypertension and bloated stomach, are formidable situations where there is a glaring need of an alternate nonumbilical entry port. Jain point offers a fresh thought, fresh perspective to laparoscopic entry in challenging situations. It is located in left paraumbilical position on a line drawn vertically upwards, 2.5 cm medial to ASIS. It is most versatile as can be used in all types of previous surgery scars. It is applicable in all body types for obesity, extremely thin and extreme lax abdomen patients.
By the medium of this book, we bring forth a new concept, a new approach which can make laparoscopic entry much safer. It can be used as a universal first blind entry port to avoid the major, retroperitoneal vessels beneath the umbilicus, a lurking fear at least in, the minds of novice endoscopist. Many a careers are nipped in the bud by the occurrence of catastrophic bleeding by major retroperitoneal vessels that lie beneath the umbilicus. By making first blind entry from Jain point this can be avoided.
This book has been presented as an atlas to clearly demonstrate a new technique. We have explained all existing entry points and their indications and contraindications, if any. We have elaborated a special section detailing the concept of Jain point entry, its evolution, rationale and ergonomics. The reader will go through the entire process by which this new safe entry port was tried, evolved and improvised over passage of time by the contributions of several endoscopy fellows and trainees over a decade. And now in its present technique, it is, almost infallible with very low complication rate, and very easy to learn and master in different clinical situations.
A separate section deals with all possible clinical situations such as in obese and very thin patients, extraordinary lax abdominal wall, large masses, previous surgeries and previous infectious pathologies. Jain point has favorable applications in general surgery also, hence, chapters defining its role in various general surgeries have been described. Ventral hernia and previous mesh hernia repair are one indication where compared to any entry point, Jain point is most suitable. Lastly a chapter on entry related complications. A chapter by endoscopy fellows on their experience of usage of Jain point entry summarizes the ease of learning._FM_22
I feel this book offers rich content with a very practical Cook Book such as steps with surgical snapshots feasible for both gynecologist and general surgeons, to help them tide over the challenging situations. It is a practical guide for budding as well as expert endoscopists.
Finding reference to Jain point in the Evidence-Based Clinical Decision Support the—UpToDate was an honor. With our several international presentations and peer-reviewed publications on Jain point, we present this book to “All Lovers and Learners of Innovations in Endoscopy”.
Nutan Jain
_FM_23Acknowledgments
As I sit to write this draft, I have immense feelings of gratitude for my fellows, trainees and junior consultants who tried Jain point, first blind port entry in laparoscopy. According to their level of expertise they kept on trying it in different clinical situations. Most of them conversant only with umbilical entry as a routine, found Jain point entry, a big relief to the lurking fear they have regarding first blind entry with sharp trocars. After having understood the anatomical rationale and methodology of Jain point they found it very easy and safe and none of them wanted to go back to umbilical entry. As their expertise grew they kept on making laparoscopic entries in previous surgery cases and other complex situations. Over last ten years the fellows and trainees kept changing but our perseverance to develop this entry point persisted. We finally managed to make the endoscopy world believe the new entry port. And this was accepted by surgeons and gynecologists alike. In situations of limitations to Palmer–s point, the general surgeons also appreciated this new approach. And I keep getting positive feedbacks from endoscopy colleagues from every corner of the world. So, I sincerely express gratitude to all my colleagues, within gynecologist, urologists and general surgeon fraternity who have used Jain point entry and have instilled in us the confidence to move ahead.
My sincere thanks to many good friends who are illustrious members of AAGL, SLS, ISGE, ESGE, MESGE, APAGE, AMASI, SELSI, IAGES, USI and ICS. Technical discussions with them, suggestions and constructive criticism have kept us motivated all through and improvised the Jain point technique.
I thank the publisher M/s Jaypee Brothers Medical Publishers (P) Ltd, Mr JP Vij (Group Chairman) has steered this company through his dynamic leadership as one of the largest medical publisher in Asia. He is duly assisted by Ms Chetna Malhotra Vohra (Associate Director—Content Strategy) and Ms Kritika Dua (Senior Development Editor). My books have been translated in Chinese, Spanish and available worldwide due to their efforts. I feel happy that rightful dissemination of medical knowledge has become a virtual reality by their efforts.
I would like to acknowledge my hospital staff especially the Gyne-Endoscopy unit who have taken pride in latest developments in the department. The Junior Doctors, Fellows and Residents and other consultants working with me have been greatly helpful and enthusiastic about the project. I would especially mention Dr Sunil Gupta, Dr Vandana Jain, Dr Aruna Arya, Dr Anadeep Chandi, Dr Kiran Kumari Mandal and Dr Parima Jain who have worked day and night to fulfill this dream project. The general surgeons and urologist Dr Siddharth Gupta, Dr Prateek Gupta and Dr Shivam Vatsal an oncosurgeon have contributed immensely in shaping up this project.
My technical staff headed by Mr Pranay, Ms Nimisha Jain and Mr Vishram Singh duly assisted by Mr Saurabh, Ms Asha, Mr Bhopal Singh have given their best in giving high quality pictures, videos and data from OT records.
In the end, I would like to raise a toast to my family for their unique help and mental support during the compilation of this book. My husband, Dr Mukesh Jain and my son Dr Anubhav Jain, both Orthopedic Surgeons, have been my pillar of strength. _FM_24Dr Vandana Jain my daughter-in-law has been most enthusiastic about the usage of Jain point and this project.
Lastly, I would like to thank my teachers and mentors who enabled me to reach this point in my career. Nonetheless, I profusely thank my patients who posed faith in my skills.
Above all, I am indebted to my late parents Mrs Vimla Gupta and Shri Ramesh Chandra Gupta who inculcated in me the spirit of, “To aim as high as possible, then, let nothing deter your faith!!.”
_FM_25Videos Title*
*The videos are available on www.emedicine360.com.