| Laparoscopic procedures have been used successfully across many medical disciplines including general surgery, urological surgery and gynecological surgery for a range of different operations since it was first used on a human by Jacobaeus in 1910. Its use in gynecologic operations is on the increase because of reduced hemorrhaging, smaller incisions, less pain and less recovery time as compared to laparotomies. As with all medical procedures, techniques, diagnoses, treatments etc., and especially since laparoscopy is a relatively new approach to surgery, research on it is constantly being done to find more advanced, efficient, and safe ways to treat patients, as well as to improve the technique and advance the science of medicine as a whole.No surgical operation is without risk of complications. Laparoscopy is no different and, in fact, carries with it risks that are specific to it. Complications specific to laparoscopy may stem from patient position, patient BMI, choice of instruments, experience of the surgeon, intra-abdominal pressure, entry technique, force required for trocar insertion, and abdominal entry point choice among others. The literature reports that complications of laparoscopic surgery happen most frequently during laparoscopic access (the entry of the Veress needle and/or trocars). Of the complications that occur during laparoscopic access, most are caused by entry of the primary trocar.Though some trocars systems are patented to have safety features that allow for the reduction of risks of certain complications, some complications, however, are still not avoided. Introduction of the primary trocar to the abdominal cavity is a procedure that carries with it the risk of hematoma of the abdominal wall, hernias, wound infection and puncture of the bowels, ureter or vasculature.Complications due to the entry of the primary trocar include abdominal wall injuries 0.24%-4.77%, gastrointestinal injuries 0.16%-0.18%, hepatic and splenic injuries 0.1% and major vascular injury (MVI) 0.084%-2.41%.Major vascular injuries are those that occur to the aorta, vena cava, iliac vessels, mesenteric vessels and other major intraperitoneal and retroperitoneal vessels including the portal vein, splenic, omental, and renal vessels.The umbilicus, the supra-umbilical and infra-umbilical regions have traditionally been used as points of insertion for the primary trocar in gynecologic surgeries. The umbilicus is used because it is a naturally weak point of the abdomen. It hides scars well and it is a prime location to access female reproductive structures in the pelvis. It is a clinically important anatomical surface landmark indicating the point at which of the aortic bifurcation is located making it not ideal in the avoidance of major retroperitoneal vessels (MRVs). The supra- and infra-umbilical regions are alternate insertion points to be used in cases where the umbilicus may be unusable due to suspicion of adhesions, when entry at the umbilicus fails in patients with abnormal BMIs in cases of enlarged uteri etc. However its proximity to MRVs and other important structures also makes it a dangerous entry point in the avoidance of access associated complications. The Lee Huang point, which lies in the midline halfway between the xiphoid process and the umbilicus, is another option for laparoscopic access that allows for a wider surgical field in cases of enlarged uteri or during the dissection of lymph nodes among other advantages. Its relationship to major vasculature, to the best of our knowledge has not been explored in the literature.Though rare, major retroperitoneal vascular injuries are acute and severe complications that may turn fatal in an instant. Though reports of MRVI complications are rare in the literature it is suggested that these injuries tend to happen more frequently at the hands of surgeons with less experience but can occur for any number of reasons, even with more experienced surgeons. Thus, knowledge of major retroperitoneal vessel (MRV) anatomy and possible alternative points for entry of the primary trocar are essential for safer entry of the primary trocar in regards to avoiding injury to the MRVs.Current common knowledge of the anatomic structures that lie beneath the traditional points of laparoscopic entry have been attained through cadaveric dissection which may not accurately reflect the in vivo condition of those structures. With technological advances, it is now possible to employ the use of computer software to recreate in vivo anatomic relationships in the form of digital three-dimensional (3D) reconstructions. This technique can be used to analyze relationships, advance common knowledge, and enhance learning.Jacobaeus noted that, in laparoscopy, there is the possibility for trocar insertion to cause injury. This study serves to employ digital 3D reconstruction techniques to assess, in vivo, the type of vessels that lie directly beneath points used traditionally for entry of the primary trocar and propose points at which insertion by the primary trocar may carry less risk of injury to major retroperitoneal vasculature.Part One Analysis of Vascular Structures deep to traditional points of laparoscopic entry[Objective]To analyze the type and frequency of major vessels deep to the umbilicus, the infr-umbilical and sub-umbilical regions and the Lee-Huang point.[Method]1.CTA dataset series from 401 patients of Nanfang Hospital with varying gynecological conditions were obtained.18 patients were excluded due to enlarged uteri2. Using Mimics 10.01 software, the data underwent processing to reconstruct the patients’ skin, bone structures including pelvis and spinal column, and abdomino-pelvic retroperitoneal vasculature in three-dimensional digital format.3. Surface landmarks were then identified and 5 points were plotted. Points at the umbilicus, lcm inferior to the umbilicus, lcm superior to the umbilicus,2cm superior to the umbilicus, and at the level of the superior margin of the first lumbar vertebra in the midline indicated locations of traditional points of entry of the primary trocar in laparoscopy. These represented the umbilicus, the infra-umbilical region, the supra-umbilical region and the Lee-Huang point, respectively.4. The types and frequencies of the major retroperitoneal vessels lying deep to the points plotted were then analyzed.[Results]1. At Point B, the presence of MRVs deep to the point is lower that any other midline point. Though lower than other points, because the overall frequency of MRV deep to this point is still relatively high, the point can not be deemed safe.2. The umbilicus is the most unsafe area in terms of chance of encountering major vessels.3. The umbilicus most often lies inferior to the aortic bifurcation.Part Two Analysis of Vascular Structures Deep to Alternate points of laparoscopic entry[Objective]To analyze the type and frequency of major vessels deep to alternate points of laparoscopic entry.[Method]1.CTA dataset series from 383 patients of Nanfang Hospital with varying gynecological conditions were obtained.2. Using Mimics 10.01 software, the data underwent processing to reconstruct the patients’ skin, bone structures including pelvis and spinal column, and abdomino-pelvic retroperitoneal vasculature in three-dimensional digital format.3. Surface landmarks were then identified and 8 points were plotted in relation to the umbilicus. The points formed a grid-like pattern with point U1, A1, B1, and C1 being points 1 cm left of points U,A,B, and C, respectively, of part 1 of this study and points U2, A2, B2, and C2 being points 2 cm left of points U,A,B, and C, respectively, of part 1 of this study.4. The types and frequencies of the major retroperitoneal vessels lying deep to these points were then analyzed.[Results]1. A trend is observed. The horizontal level lcm superior to the umbilicus is most safe in the avoidance of MRVs and the further the deviation from the midline, the less the risk of encountering a MRV. |
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