The stem
You are scrubbed in for a laparoscopic cholecystectomy. The surgeon hands this to you before the first port is placed.
The equipment
The examiner’s questions
Question 1What is this, and what is it used for?Show the model answer
A Veress needle. It is used to make the pneumoperitoneum, the space created by blowing carbon dioxide into the abdomen, in the closed technique before the first trocar is inserted.
Question 2How does it protect the bowel?Show the model answer
Inside the sharp outer needle is a blunt, spring-loaded inner rod. While the needle passes through the abdominal wall the rod is pushed back. Once the tip enters the peritoneal cavity the resistance disappears and the rod springs forward, covering the sharp tip.
Question 3How do you confirm the needle is in the peritoneal cavity?Show the model answer
You feel two clicks as it passes the fascia and the peritoneum. Then: an aspiration test returns no blood or bowel content; saline injected flows freely and cannot be drawn back; a drop of saline on the hub falls in (the hanging-drop test); and the opening pressure on the insufflator is low, usually below 8 to 10 mmHg. Insufflate to 12 to 15 mmHg.
Question 4What are the risks, and what are the alternatives?Show the model answer
Injury to a major vessel such as the aorta or iliac vessels, bowel injury, insufflation outside the peritoneum, surgical emphysema and gas embolism. Alternatives are the open (Hasson) technique at the umbilicus, or entry at Palmer’s point, 3 cm below the left costal margin in the midclavicular line, when adhesions are expected around the umbilicus.
After you answerThe teaching pointShow
Most serious entry injuries happen at the first step, before the camera is in. Know your checks, and use the open technique if you are in any doubt.
The drawings were made for this site. The patients are written for teaching and are not real.