Advantages of open access technique in patients with previous laparotomies:
The incidence of visceral and vascular injuries is significantly reduced.
■ The risk of extraperitoneal insufflation is eliminated.
■ Trocar site incisional hernia formation is decreased because the fascia is closed as part of the technique.
■ In experienced hands, the open technique is cost effective and does not significantly increase the operative time.
Several open laparoscopic techniques have been described. The most commonly used is the Hasson technique (2). This is a safe method to enter the abdomen under direct open vision, and is especially suited for patients with abdominal adhesions from previous surgeries. A small (1-2 cm) skin incision is made away from previous scars. Blunt dissection is carried out until the anterior abdominal fascia is identified. The fascia is incised and the muscle fibers are spread. The underlying peritoneum is elevated aEthicon, Somerville, NJ.
bU.S. Surgical Corp., Norwalk, CT.
with hemostatic clamps and incised. Two heavy, absorbable sutures are placed on either side of the fascial incision to secure the trocar in place and to prevent gas leakage. A 10-12 mm port with blunt trocar is inserted and CO2 insufflation is performed through the port valve. The other ports are inserted under direct laparoscopic visualization away from adhesions. The preplaced fascial sutures are tied together at the end of surgery to close the defect.
Another open technique involves a small incision over the everted umbilicus at a point where the peritoneum is closest to the skin. This technique can be used in pediatric patients and in patients with previous surgery provided there is no midline incisions, portal hypertension, recanalized umbilical vein, umbilical pathologies such as a urachal cyst, sinus, or umbilical hernia. The umbilicus is everted with toothed grasping forceps and is incised in the sagital plane. Two small retractors are inserted to expose the umbilical pillar or canal that runs from the undersurface of the skin down to the linea alba. Blunt dissection through this plane permits direct entry into the peritoneum. Once the peritoneal cavity is opened, a laparoscopic port with blunt internal trocar is then inserted under vision and insufflation started.
Lal et al. described a similar open technique without umbilical eversion whereby the umbilical cicatrix tube is used as a landmark to follow down to the linea alba where the peritoneum is adherent to the undersurface of the fascia. A supra- or subumbilical sagital incision is used, provided no midline scar is present. This technique was performed in 525 consecutive cases with no complications or port site hernias (3). Another modification of the umbilical access named the mini-open technique or the umbilical stalk technique uses a 5 mm transumbilical incision and placement of a 5 mm blunt cannula without the trocar. The original authors employed this technique for four years in 600 patients without a midline laparotomy incision incorporating the umbilicus, and have accessed the abdomen safely for laparoscopy without any complications (4).
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