Direct trocar insertion through Palmer's point with 10 mm trocar OR Veress needle insufflation prior to trocar entry through Palmer's point? Which one is preferable or practiced?
The neumoperitoneum insufflation for some patients or procedures can be very tricky or sometimes even risky. Although it seems that around the world the Veress Needle through the umbilicus is still the most popular technique, it's risk for visceral or vascular puncture/perforation is well recognized and a potentially life-threatening hazard for the patient. We have to remember that the original purpose that Janos Veress assigned to needle was to drain the thoracic cavity and obtain samples of pleural and peritoneal effusions, not to insufflate any gas into these cavities. The Hasson's and Palmer's technique came later along improving safety while insufflating CO2, by the way, both were GYN surgeons.
The technique described by Raoul Palmer required a Veress needle to be inserted through all the layers of the abdominal wall at a point specifically located at the left mid-clavicular line, one fingerbreadth below the left costal margin, this means lateral to the rectus abdominis muscle and enough under the rib to avoid its neurovascular bundle. In comparison to the traditional Veress' technique it seemed safer to insert a needle there because the major vessels (aorta and vena cava) are avoided and there is much less preperitoneal fat, if any, at this point.
However, I've never tried to directly insert a laparoscopic trocar without previous insufflation. I think that may be unnecessarily risky for the patient, because of the force/pressure that you have to apply to the instrument while inserting it. Although I don't have any data to support my conclusion.
The Palmer's technique helps me to insufflate some of my Nissen's (when I want to use only 5-mm trocars), some of my Gastric Bypasses, most of my Splenectomies and most of my Ventral Hernias. In my experience is very safe (no complications related to it's use until now) and faster than the original Veress' technique. I usually succeed insufflating at the first attempt.
As a low-tech alternative, in an splenectomy case when the Palmer's technique didn't work after 2 attempts, I decided to enlarge the skin incision to 12 mm, I used my S-shape curved retractors to expose the fascia, I bluntly separated the muscular fibers with a pair of Kelly's clamps and finally I perforated the abdominal endoaponeurosis with my index finger. Then I inserted a 12 mm laparoscopic cannula (without the trocar) into the peritoneal cavity and started the insufflation of CO2.
Another very high-tech option would be to use the "opti-view" system, where the surgeon observes with a laparoscopic camera how a bladeless trocar advances through the abdominal wall layers until it reaches the peritoneal cavity.
I use Palmer's point entry frequently for GYN cases for TLH of the large uterus, laparoscopy in pregnancy, or prior open abdominal procedures. I agree with Antonio's answer above. Major complications from any standard type of laparoscopic entry are so uncommon that no study will liekly ever proove one method or device to be superior in safety to another.
I perform Veress needle entry at Palmer's point, then use a 5 mm Optiview trocar under direct vision. The landmarks of the abdominal wall are different at Palmer's point, so once you encounter the fascia and abdominal wall musculature, the next adipose tissue you see will be the omentum or bowel mesentery, not pre-peritoneal adipose.
This is a safe and reliable entry method. I teach this to all of my registrars.
We have moved from veress needle to direct trocar insertion for umbilical port long back to reduce injury to viscera.
Why not same is true for Palmer's entry.
Niraj, has this reduced your injury rates to viscera? What about major vascular injury?
I used palmers point in patients with previous midline subumbilical scar. It appears easy and safer to creat pneumoperitoneum with a veress needle before inserting a 5mm trocar. In most OBGYN procedures orientation is better when the laproscope is at the centre. I often use palmers point to visualise my point of entry at the umbilicus to exclude adhesions from previous scar.
It is proved again and again Direct Trocar entry (with 10 mm trocar) through umbilical port is far better than Veress needle. Then why not same for Palmer's point entry.
And I have been using same direct trocar 10 mm for Palmer's point entry since last 9 years, and never faced any difficulty or any complications.
Recently came to know that, many surgeons are still using Veress needle for pneumoperitoneum and then inserting 5 mm trocar and not 10 mm through Palmer's point.
But why?
The rate of major complications is so low that this is a question that may never be definitely answered. Entry at Palmer's point is different than entry at the umbilicus, so studies of one may not be generalizable to the other. Minor complications (pre-peritoneal insufflation, failed entry, omental injury) are more common with Veress entry. How important is that?
Many specialty societies consider Veress, direct, open techniques all to be acceptable first line methods. One should have a routine method, and a back-up in the event it isn't suitable for a particular patient.
The risks of a learning curve probably outweighs any safety gained by learning a new technique that may or may not improve safety by a small amount.
Just read this article a few weeks ago discussing this very topic.
http://www.ncbi.nlm.nih.gov/pubmed/?term=25460522
Safety precautions in Minimal Acess surgery is key. Perfection in a particular way of doing things safely is important. Granted sir that you may have been successful all this years with direct trocker insertion at palmers point but some times oid way of doing things are not let go easily provided they appear safe.
Safer to use Verress Needle but remember the anatomy of the muscular is fascia because there are 4 clicks at this point of entry rather than the two if you enter through the umbilicus.
We always use first the verres neddle before placing a trocar. It might be sure and we hadn´tnoticce Major complications
Most gynecologist are familiar with the Veress needle , yet the Direct Optical Entry (DOE) is another option. Regardless of the technique you choose ,we recommend :
Laparoscopy and natural orifice surgery: first entry safety surveillance step.
Tsin DA, Tinelli A, Malvasi A, Davila F, Jesus R, Castro-Perez R.
JSLS. 2011 Apr-Jun;15(2):133-5. doi: 10.4293/108680811X13022985131813.
PMID: 21902961
http://www.slideshare.net/tsin/laparoscopy-and-natural-orifice-surgery-safe-practice-modification
One should also keep this technique in mind.
Experience with the Bailez technique for laparoscopic access in children. Franc-Guimond J, Kryger J, González R. J Urol. 2003 Sep;170(3):936-8.
PMID: 12913745
we have not yet tried palmers point entry.we are still doing direct umblical and veresse entry and no such complication have been encountered.
verres needle, but the new version of direct trocar access shows the safety blade when it works on
Always an initial "gassed" entry with Veress needle (aim for IAP
I would recommend using the Veress needle first & insufflation of the abdomen before inserting the trocar as it is safer to practice
I also use Veress needle at umbilical port, mostly in patients with previous surgeries. In very difficult cases I use Palmer´s point. For me the hole in the bowel from Veress needle is less dangerous than from a trocar...
Lets put it this way.
Do you prefer DTI at umbilical port or Veress needle? We have moved from Veress needle to DTI at umbilical port because of its superiority. Why same is not applicable for Palmer's point entry.
I think that everyone should use the technique that he is familiar with and there are no major concern in experienced hands. We should always keep in mind that in previously operated patient, if you encounter a problem with veress or direct insertion it is then so difficult to justify your approach legally. The use of the hasson technique is safer and should be advocated in these cases.
I prefer VERESS but if to use DTI use the optiview that is safer
you can use it also in palmer
Fouad and Zvi,
Could you please provide references showing that Hasson is safer in patients with previous surgery, and that the optiview trocar is safer for DTI? I think that is the point of the whole discussion. There is little evidence showing that any one method is superior to another as all are safe. Some authors argue that there would be more complications from the learning curve of surgeons changing entry technique compared to any small increment of safety if one technique were safer by a very small degree.
I prefer entering the abdomen through Palmer point using verres needle
Me too verres needle first. The only time I use 10 mm or 5 mm trocars first is with the special ones like optic-view that you can see the different tissues while getting in.
It seems safer to enter Verses needle first at that point but at umbilical entry I prefer direct trocar entry
We always use direct vision with blunt optical trocar and laparoscope (5 or 10mm). We can visualise each layer of the abdominal wall, then visualise peritoneum and omentum or bowel directly. The degee of safety is much higher.
With the patient lying flat use a disposable Verres needle vertically through an incision at the base of the umbilicus and feel the two characteristic clicks and as long as the pressure is less than 12 mm Hg you know you are in the correct place.
I use the Palmer point in obese patients, specially in bariatric surgery; I prefere to use the Veress neddle, followed by the optical trocar puncture at the umbilical site.
well said Dr Jose. however in bariatric surgery you may have to remove the palmers point point to proceed or do you convert that as a second port?
I remove the needle and use this site for the trocar of the right hand.
When approaching the abdominal cavity via Palmers point, I still use the Veress needle as the first choice.
The first choice is the use of Verres needle vertical insertion in the intraumbilical scar lifting the anterior abdominal wall and establishing two clicks for peritoneal entry. The intra abdominal pressure should be
Laparoscopic entry techniques
Overall, there is insufficient evidence to recommend one laparoscopic entry technique over another.
Ahmad G, Gent D, Henderson D, O’Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database of
Systematic Reviews 2015, Issue 8. Art. No.: CD006583. DOI: 10.1002/14651858.CD006583.pub4.
Dear José Gustavo Olijnyk the Veress needle in the obese female is used trans vaginal into the recto-uterine pouch (Douglas) .
Dear Daniel Tain,
Would not work if you are dealing with severe recto-vaginal septum infiltrating endometriosis. Indeed it would be dangerous.
Prof Chris Sutton
Dear Dr. Christopher Sutton you are right. The patient selection is the same as per culdoscopy , culdolaparoscopy AKA transvaginal NOTES. The technique is not new and was used in obese patients with no obliteration of the posterior fornix or the Pouch of Douglas
veress needle , but you can also use the new- optic-view trocars which allow you to see trough the different layers
You are right @ Div Vaknin however, this is not readily available or affordable in most resource poor centres but definitely the ideal because of its high safety margin not only for palmers entry but for all entry points.
verres needle firstly...before entry ı recommend nasogastric tube for all patients, also douglas could be used for verres safely except deep infiltrative endometriosi patients with rectal nodule.
Verres needle directly unless there is a history of previous abdominal surgery which would influence underlying intrabdominal tissues, where Hasson should apply.
It depends on surgeon experience and the using veress or Hasson technique should selected according the case, surgeon experience,operative facilities.
In 193,318 entires into the female abdomen for laparoscopic steriliizations I've used not used Veress needle at all, all the entries is by Direct Trocar insertion - no complications at all. Periumbilical area is been my choice. I had no opportunity to use Palmer's point to enter the abdominal cavity.
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