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
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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
- Anadeep Chandi MS(Obs & Gyne) DNB
- Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Anshu Gupta MS(Obs & Gyne)
- Senior Resident
- Department of Obstetrics and Gynecology
- All India Institute of Medical Sciences
- Rishikesh, Uttarakhand, India
- Artin Ternamian MD FRCSC
- Associate Professor
- Department of Obstetrics and Gynecology
- Faculty of Medicine
- University of Toronto
- St Joseph–s Health Centre, Toronto
- Division of Gynecological Endoscopy
- Toronto, Ontario, Canada
- Aruna Arya MBBS MD
- Assistant Professor
- Department of Anatomy
- Muzaffarnagar Medical College
- Muzaffarnagar, Uttar Pradesh, India
- Aruna Tantia MBBS MS DGO Diploma in Gynecology-Endoscopic Surgery(Germany) FMAS
- ILS Hospitals
- Kolkata, Howrah, Dum Dum, Agartala
- Baris Mulayim MD
- Saglik Bilimleri University
- Antalya Education and Research Hospital
- Associate Professor
- Department of Obstetrics and Gynecology
- Supervisory Board Member of Turkish Society for Gynecological Endoscopy
- Vice-President of Antalya Branch Office of Turkish Gynecology and
- Obstetrics Society
- Antalya, Turkey
- Bhumika Bansal MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Chetna Agarwal MS(Obs & Gyne)
- Research Fellow in Gynecology-
- Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- CS Ramesh Babu MSc(Biology)
- Associate Professor
- Department of Anatomy
- Muzaffarnagar Medical College
- Muzaffarnagar, Uttar Pradesh, India
- Gunjan Saxena MS(Obs & Gyne)
- Head, Department of Reproductive Medicine and Fertility
- Apollo Spectra
- Amritsar, Punjab, India
- Harry Reich
- Retired
- Honorary Member, AAGL
- Past President, ISGE, SLS
- Southern Ocean Medical
- Center, Hackensack—Meridian Health Center, New Jersey, USA
- Jonathan M Reich MD
- Chairman
- Department of Surgery
- Southern Ocean Medical
- Center, Hackensack—
- Meridian Health Center
- New Jersey, USA
- Kaustubh Srivastava MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Kiran Kumari Mandal MS(Obs and Gyne)
- Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Medhavi Tomar MS(Gen Surg)
- General and Laparoscopic Surgeon
- Star Hospital and Laparoscopic Surgical Center
- Meerut, Uttar Pradesh, India
- Monika Ranwa MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Nutan Jain MS
- Director
- Department of Obstetrics and Gynecology
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Parima Jain MBBS MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Prateek Gupta MBBS MS(Gen Surg) MAMC(Delhi) MCH(Urology)
- Department of Urology
- All India Institute of Medical Sciences
- Jodhpur, Rajasthan, India
- Praveen Bhatia MBBS MS(Gen Surg)
- Consultant Surgeon and Medical Director
- Bhatia Global Hospital and
- Endosurgery Institute
- New Delhi, India
- Priyanka Bansal MS(Obs & Gyne) FICOG
- Associate Professor
- FH Medical College
- Agra, Uttar Pradesh, India
- Rhythm Bhalla MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Rooma Sinha MD DNB MNAMS
- Hon. Professor (AHERF)
- Senior Consultant Gynecologist
- Minimal Access and Robotic Surgeon
- Apollo Health City
- Hyderabad, Telangana, India
- Rupa B MS
- Consultant
- Apollo Health City
- Hyderabad, Telangana, India
- Shivam Vatsal ASI ISO IASO
- Senior Consultant
- Department of Surgical Oncology
- Sarvodaya Hospital and Research Center
- Faridabad, Haryana, India
- Siddharth Gupta DNB(Gen Surg) FMAS FIAGES
- Lifetime Member of ASI, SELSI and IHS
- Fellow (Pursuing) in Advanced Laparoscopy and Robotics
- Gastroenterology Medical Centre and Hospital
- Coimbatore, Tamil Nadu, India
- Sonam Singh MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Sonika Mann MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Sonil Srivastava MS(Obs & Gyne)
- Consultant Laparoscopic Surgeon
- Lake City Hospital
- Sunil Gupta MS(Gen Surg)
- Director
- Jyoti Nursing Home
- Muzaffarnagar, Uttar Pradesh, India
- Swati Dubey MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Swati Kanawa MS
- Laparoscopic Surgeon, Infertility Specialist and Gynecologist
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Swati Varshney MS(Obs & Gyne)
- Research Fellow in Gynecology-Endoscopy at
- Vardhman Super Specialty Hospital
- Muzaffarnagar, Uttar Pradesh, India
- Vandana Jain MS
- Consultant
- Department of Obstetrics and Gynecology
- Vardhman Super Specialty Hospital
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
_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
_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
_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
_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*
- What is Jain point
- Direct trocar entry through Jain point
- Jain point entry in a case of previous cesarean section
- Jain point entry in flabby abdomen
- Jain point entry in obese patient with previous cesarean sections
- Jain point entry in thin patients
- Jain point entry in a very thin patient with large broad ligament myoma
- Jain point entry in very large myomas
- Jain point entry in a large dermoid cyst
- Laparoscopic management of endometriotic rectovaginal nodule
- Laparoscopic management of extensive endometriosis
- Jain point usage in Burch colposuspension
- Jain point entry in case for paravaginal defect repair
- Laparoscopic pectopexy
- Laparoscopic management of cesarean scar ectopic
- Laparoscopic isthmocele repair
- Tubo-tubal reanastomosis
- TLH with extensive endometriosis
- TLH with extensive adhesions
- TLH with large broad ligament myoma.
*The videos are available on www.emedicine360.com.