Optical Trocars

This is one of the techniques used to insert the initial trocar in patients with previous laparotomies. After pneumoperitoneum is obtained with the Veress needle, a 1 cm long incision is performed away from previous scars. Towel forceps are used to elevate the abdomen, and an optical trocar is introduced with the 0 degree telescope. The optical trocar is advanced slowly through the different planes of the abdominal wall using a full 180 degree rotational movement. The blunt blade at the tip of the trocar spreads the tissue under direct visual control. Entry into the peritoneal cavity is readily documented. This decreases the risk of injury to intra-abdominal organs. Thomas et al. used the optical access trocar as the initial trocar in 1283 urological laparoscopic procedures. The optical trocar was inserted at the umbilicus in 7.4% of patients, in the right upper quadrant in 34.7%, and in the left upper quadrant in 58.5%. There were four injuries (0.31%) associated with the optical access trocar, including one bowel injury, one mesenteric with retroperitoneal hematoma, and two epigastric vessel injuries (5).

For a previously operated abdomen with a midline incision, the Veress needle should be placed in the upper left quadrant of the abdomen just lateral to the rectus sheath. Transrectus insertion of the Veress needle is discouraged because of risk of injury to the inferior epigastric vessels.

Previous abdominal surgery does not appear to affect adversely the performance of subsequent urological laparoscopy.

Previous abdominal surgery does not appear to adversely affect the performance of subsequent urological laparoscopy.

Of 700 patients presenting to a single center for urological laparoscopy, 48% had a history of abdominal surgery. Overall, patients with no history of surgery compared to those with such a history tended to be older, predominantly female, and at significantly higher operative risk. Patients with a history of surgery who underwent nephrectomy or pyeloplasty were also more likely to have received blood transfusion perioperatively, which was probably related to their increased age and higher degree of medical comorbidity. There were no significant differences in operative blood loss, rate of conversion to open procedure, or rate of operative complications (6).

In general, commonly recommended tests include prothrombin time, partial thromboplastin time, complete blood cell count with platelet count, and in some patients, bleeding time.

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