Transperitoneal access to the pelvis

The indications for transperitoneal access to the pelvis are:

? Cryptorchidism

? Colposuspension

? Pelvic lymph node dissection

? Radical prostatectomy

? Varicocelectomy

? Hernioplasty.

The patient lies in a deflected supine position with a 30? Trendelenburg decline. Before trocar placement, a 14F Foley catheter is inserted to drain the bladder. There are two techniques for placement of the first trocar at the umbilical level:

? Creating a pneumoperitoneum with the Veress needle

? Open mini-incision closed with a blunt trocar (Hasson technique).

The Veress needle is inserted at a 45? angle into the empty peritoneum at the umbilical level. The position should be checked by aspiration, infusion of 5 ml of saline, and the intra-abdominal pressure carefully observed to be below 12 mm Hg during insufflation (initially below 5 mm Hg). The disposable Veress needles with a safety shield is safer than the reusable ones. Alternatively, particularly for children, a small needle with a sheath for insertion of a miniature telescope can be used.

Previous major abdominal surgery is a relative contraindication to blind-needle insertion and a Hasson cutdown technique should be used for the first port. The arrangement of the working ports depends on the procedure, as, for example, in Figure 4. All the secondary trocars have to be placed under endoscopic control. Except in case of cryptorchidism, the first operative step represents the exposure of the Retzius space. This can be accomplished via an incision lateral to the lateral umbilical ligament, e.g. as in pelvic lymph node dissection, or after high transection of the urachus and both lateral umbilical ligaments, e.g. as in radical prostatectomy or colposuspension.

Figure 4. Laparoscopic radical prostatectomy: arrangement of trocars.

2.4.4 Extraperitoneal access to the pelvis

The indications for extraperitoneal access to the pelvis are:

? Colposuspension

? Pelvic lymph node dissection

? Radical prostatectomy

? Varicocelectomy

? Hernioplasty.

There are two techniques:

Balloon dissection- After a 15 mm subumbilical skin incision, the transverse fascia is explored by a blunt mid-line dissection. The index finger or the telescope can be used for preliminary dissection of the extraperitoneal space. Then, a balloon-trocar system is introduced and the dissecting balloon is filled with 1000-1200 ml of saline, according to the patient's size. The balloon dissection can be monitored endoscopically with the laparoscope inserted in the balloon-trocar sheath. The balloon is kept inflated for 5 minutes to provide adequate haemostasis. After desufflation and retrieval of the balloon catheter, a 12 mm trocar (Hasson trocar) is inserted and fixed with an airtight mattress suture and connected to the insufflator (maximum pressure 15 mm Hg). It is then possible to insert the working trocars in a similar manner to the transperitoneal approach.

Finger dissection- The index finger is introduced via the suprapubic incision. The digital dissection allows adequate exposure of the Retzius space. The trocars are then placed only under palpatory control (e.g.10 mm subumbilical, 5 mm pararectal).

The extraperitoneal approach to the pelvis allows direct access to the pelvic organs, but it has the disadvantage of a smaller working space.

Date: 2016-06-13; view: 9