| BackgroundThe new technology revolution sweeping across the world and the rapid progress of biotechnology, information technology, new materials, new energy resources and other new technologies have brought tremendous impact on all traditional applied sciences and new vitality to minimally invasive medicine. Minimally invasive surgery is a technique that minimizes the wounds of surgical procedures using imaging system and mini-sized instruments, which is the milestone in the development of surgery in the 20th Century, as well as the anesthesia, aseptic techniques, nutritional support and organ transplantation, and the trend for and future of the development of surgical sciences in the 21st Century. Laparoscopic surgery, an important component of minimally invasive surgery, is among the most brilliant ones.Laparoscopic surgery has developed for a very long time. In 1805, German physician Philip Bozzini started to inspect urethra with endoscope. In 1901, Dr. George Kelling, a German surgeon, performed the first laparoscopy on an animal. However, for a long time, as an invasive instrument for abdomen examination, laparoscope was not used in treating the lesion it had detected. Kurt Semm from Germany made great contribution for the development of laparoscopic instruments and surgical techniques. In 1964, he invented the automatic CO2 insufflator, intra-abdominal pressure monitoring system and many other laparoscopic instruments, and conducted a lot of training on laparoscopic surgery. The rapid progress of laparoscopic surgery is also closely related to the development of modern industrial technologies, such as optical fiber, radiography, monitor, harmonic scalpel, stapler and robot-assisted laparoscopy, which has aroused unprecedented enthusiasm of surgeons for laparoscopic surgery. In 1987, French gynecologist Philippe Mouret successfully completed the first laparoscopic cholecystectomy in the world, and from then on, laparoscopic surgery was universally accepted for its advantages including small incision, little bleeding, small wound, minor pain, quick recovery, proved esthetic effect, and short hospital stay, etc., and was rapidly popularized and adopted around the world. Now laparoscopic cholecystectomy is considered the "gold standard" for the surgical treatment of gallstone disease. After three decades’ development, laparoscopic technique has been applied in all kinds of abdominal surgeries, and was tried in almost all the traditional open abdominal surgeries. The new concept "minimally invasive surgery" has been widely accepted, and more and more surgeons in China begin to study and perform this kind of surgeries.Because of the unequal economic growth, the development of laparoscopic surgery in China is not equal among the regions, especially in primary hospitals. The slow development in some regions also owes to the lack of training on laparoscopic techniques and the fear of some special complications caused by laparoscopic equipments and instruments. Then how can we avoid the disadvantages of laparoscopic surgery and promote the progress of laparoscopic techniques? We need to continue to explore and summarize, to further understand the laparoscopic equipments and instruments and the anatomical structure of human bodies, and, most of all, to make comprehensive analysis on laparoscopic surgeries, so as to avoid the technical complications.Study ObjectFor most laparoscopic surgery, to establish artificial pneumoperitoneum is the first and a necessary step. Pneumoperitoneum helps to expand the space between the abdominal wall and the organs to provide sufficient room for the operation and reveal the operating field clearly, so as to facilitate the operation, and prevent injuries of organs and major vessels when the trocar is inserted. The insertion of Veress needle may cause injury in large vessels and organs in the abdomen, resulting in bleeding, perforation, air embolism and other complications, which scared a number of learners of laparoscopic surgery. Now, the most commonly used method for creating pneumoperitoneum is inserting the needle through the 10 mm incision made at the superior or inferior margin of the umbilicus. The inner stylet of Veress needle is hollow and has a dull tip and a hole in the sheath, through which gas and water can be injected. The inner core is spring-loaded so that it retracts into the shaft of the outer cannula when encountering resistance when penetrating through the abdominal wall, and springs forward when the tip of the needle enters the peritoneal cavity. This inner stylet can protect any viscera from injury by the sharp outer cannula. During the puncture through the incision at the superior or inferior margin of the umbilicus, the performer normally experiences the sense of penetrating through twice, for the needle passes through 4 layers:subcutaneous fat, fascia (or muscle), preperitoneal fat and peritoneum. However, it’s difficult for the performer to make a correct judgment. For example, the overly tight or loose fascia-to-peritoneum adhesion makes it difficult to feel the sense of the second penetrating through, leading to unsuccessful puncture or injury of viscera. The very middle of the umbilical base is the healed scar of the umbilical cord, where there is few vessels, the thinnest tissue layer, skin tightly clinging to the fascia, no preperitoneal fat and muscle, fascia adhered tightly to peritoneum, even in fat people. Theoretically, Veress needle puncture through a 1 mm incision made in here, passes the shortest path, and the puncture succeeds after feeling one sense of penetrating through, which is easier for the performer to handle and to make a correct judgment. However, it is still not confirmed in actual practice. Therefore, we decided to do this comparative study of establishing pneumoperitoneum by puncture through umbilical margin and umbilical base in learners of laparoscopic surgery, aiming to provide a simple and safe method for creating pneumoperitoneum, and shorten the learning curve for learners of laparoscopic surgery.Materials and Methods1. Selection of Learners of laparoscopic surgery. From January 2010 to September 2011,36 surgeons who were receiving in-service training, or just graduated, or on their internship received training on the basic theories of laparoscopic surgery, and participated in this study. Each learner was assigned to 10 Veress needle punctures. Those who had done more than 20 laparoscopic surgeries are excluded.2. Selection of Patients.360 patients who are scheduled for laparoscopic surgery were included in this study regardless of their sex, age, somatotype and disease. Those who had undergone laparotomy incision at the margin of umbilicus or those with ileus or abdominal trauma were excluded. The patients were ordered by the date of operation, and were divided into two groups, each has 180 patients, and those at the odd positions in Group A, and those at even positions in Group B. Patients in Group A received puncture through umbilical base, while those in Group B received puncture through umbilical margin. The punctures were performed by the learners of laparoscopic surgery. Each learner was responsible for 5 patients from Group A and 5 from Group B. Routine cleaning and disinfection of umbilical region were conducted on all patients.3. Puncture Methods3.1 Puncture through umbilical base in Group A. The umbilical base was revealed by the assistants using vessel clamps with curved jaws, a 1-2 cm incision was made in the middle of the umbilical base, the skin on both sides of the incision was clamped with two towel clamps, and the Veress needle was inserted into the abdominal cavity through the incision, during which the sense of penetrating through was felt once normally.3.2 Puncture at the margin of umbilicus in Group B. A 10-12mm incision was made at the superior or inferior margin of the umbilicus, the skin on both sides of the incision was clamped with two towel clamps, and the Veress needle was inserted into the abdominal cavity through the incision, during which the sense of penetrating through was felt twice normally.4. Observation. Records of the data of the two types of puncture by learners of laparoscopic surgery were established. The clinical information of patients, time of puncture, attempts, success rate, and intra and post-operation complications were observed and recorded. The success of a puncture was judged by performers’sense of penetrating through, and dripping test was performed once a successful access into the abdomen is considered. A CO2 insufflator was connected if dripping water was produced. The intra-abdominal pressure was set at 13mmHg, and the flow rate at 2～ 3L/min. The pneumoperitoneum was considered successful if the insufflation was successfully completed and the abdominal wall bulged. A second or third puncture was conducted if the sense of penetrating through was not felt, or the dripping test or insufflations failed. And the establishing of pneumoperitoneum is considered unsuccessful if all three punctures failed, and the patients received open access instead or were transferred to the teachers. A 10-12mm incision was made at the superior or inferior margin of the umbilicus for patients from Group A, and then patients from both groups underwent trocar insertion and endoscope placement to detect puncture-related complications.5. Statistical Analysis. SPSS for Windows 13.0 software package was used to analysis data. Each data was to be normality tested (Shapiro-wilk). If the data accorded with normal distribution, measurement data was signified by mean (±) standard deviation(x±s), T test was adopted to measure the data of two groups. If the data did not accord with normal distribution, measurement data was signified by median (the upper and lower quartiles), Non-parametric test was adopted to compare the measuring data of two groups (Mann-Whitney U test).x2 test and exact test was adopted to compare the count data of two groups. If it showed (P<0.05), it means that difference was statistically significant.ResultsA total of 13 punctures failed, of which 2 were from Group A (puncture through umbilical base), and 11 from Group B (puncture at the margin of umbilicus), and patients were transferred to the teachers or received open access instead. The time for the successful punctures ranges from 1 to 15 minutes. The two groups were not significantly different in age, sex, BMI and type of disease (P=0.843,0.526,0.149, 0.414), but were significantly different in total success rate, one-attempt success rate and puncture-related complications (x2=6.464,12.085,4.595, P=0.011,0.001,0.032). Group A showed higher total success rate and one-attempt success rate, and fewer complications than Group B; complications related to the puncture include extraperitoneal emphysema, injury and bleeding of greater omentum and mesenterium, and no injury of intestine, bladder and abdominal large vessels was detected.The difference in total success rate and puncture-related complications are particularly significant in patients with BMI>25kg/m2 (x2=8.580,7.017; P=0.003, 0.008). Group A showed higher total success rate and significantly less complications than Group B.The difference in total success rate and puncture-related complications are not statistically significant in patients with BMI<25kg/m2 (P= 1.000,1.000). Group A showed higher one-attempt success rate (x2=5.429, P=0.020). No puncture site infection occurred after the surgery.Conclusion1.It is easier to create pneumoperitoneum with Veress needle puncturing through umbilical base than through umbilical margin.2.Establishing pneumoperitoneum by puncture through umbilical base showed less complications than through umbilical margin. It is a safer method.3.For obese patients with BMI>25kg/m2, it is more safer and easier to create pneumoperitoneum with Veress needle puncturing through umbilical base than through umbilical margin. The former is the ideal way of creating pneumoperitoneum. |
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