Placing the trocars
Correct trocar placement facilitates any laparoscopic procedure, especially when dense adhesions are present. First determine the insertion sites, then select the type of entry technique and the length of the trocars.
Insertion sites. In most cases, the primary trocar is placed at the umbilicus. However, in a laparoscopy being performed for adhesions or in patients who have had an umbilical hernia operation or a vertical abdominal incision, place the primary trocar in the left upper quadrant. The reason: This region usually is spared from the formation of dense adhesions; therefore, entry can be performed safely by placing the trocar in the midclavicular line just below the lowest rib.
From that position, examine the abdomen for bowel adhesions to the anterior abdominal wall. If present, excise these adhesions prior to placing a trocar at the umbilical site. (It often is unnecessary to move the camera to the umbilical port, as the view with modern optical equipment from the left upper quadrant is more than adequate.)
Further, surgery can be eased by spacing the trocars as widely apart as possible and placing them on the same side of the patient.
Entry techniques. An alternative to direct trocar placement in highrisk patients is to use the open trocar insertion technique. First, make an abdominal incision and then insert the trocar through it. While some believe that this method reduces the risk of bowel perforation, the survey data from the American Association of Gynecologic Laparoscopists (AAGL) have not supported this theory.3
Trocar length. To determine the proper length, consider the thickness of the patient’s abdominal wall and the distance from the trocar to the adhesion. Trocars that are too long prevent the grasper jaws and scissors from opening, while those that are too short keep slipping back into the retroperitoneal space.
After all the trocars have been placed, carefully inspect the pelvic cavity because the peritoneum becomes more opaque as surgery progresses, obscuring anatomical definition.
Divide and conquer
To excise the adhesion, grasp it from the side contralateral to where you plan to make the first cut. Traction on both the organ and the adhesion is essential to establish the correct tissue planes, which in turn ensures adequate and safe excision of the adhesion. Because the bowel is the organ commonly involved in the adhesive process, there are many graspers available for atraumatic manipulation, including the Duval and Pennington forceps. Avoiding injury to the bowel is paramount to the procedure, as trauma will cause more adhesions, worsening the patient’s condition.
After grasping the adhesion, select a method by which to divide and remove it. This selection is based on the surgeon’s experience, the location of the adhesions, and the organs involved. In most cases, laparoscopic scissors are the instrument of choice. However, opt for electrosurgery (unipolar and bipolar), carbon dioxide laser, or ultrasonic energy (see “Tools for excision”) when energy is needed as a secondary source of hemostasis.
Begin by excising superficial adhesions. This ensures unimpeded access to deeper adhesions in case bleeding occurs. In electrosurgery, slowly pass the probe near the adhesion, allowing the electrons to arc from the instrument tip to the tissue. Proceed with extreme care when using unipolar energy near vital structures because electrons travel the path of least resistance. For example, if there is an adhesion between a loop of bowel and the uterus, always resect the adhesion from the bowel first. The reason: If you remove the adhesion from the uterus first, electrons would flow toward the bowel while you excise the adhesion from this organ. This is because it is the only path remaining for the electrons to egress, as you already have severed the adhesion from the uterus. The end result: thermal damage to the bowel.
When extremely thick or vascular adhesions are encountered, coagulate them prior to division as follows: First, achieve hemostasis using bipolar forceps. This instrument allows the precise application of energy to the tissue because electrons flow from one side of the forceps to the other, rather than through the body as with unipolar electrosurgery. Apply the energy until the tissue is desiccated and the high resistance stops electron flow. Second, divide the tissue using laparoscopic scissors. Bipolar electrosurgery also should be used when coagulation is needed near vital structures such as great vessels, the bowel, bladder, and ureters.
A new type of electrosurgical generator seals vessel walls rather than coagulating them (LigaSure; Valleylab, Boulder, Colo). This results in a much higher vessel burst strength than either unipolar or bipolar electrosurgery, allowing the surgeon to close vessels up to 7 mm in diameter prior to division of the vascular adhesion.