Surgical Techniques
How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy
By arming yourself with knowledge of the most common complications—and their causes—and employing well-chosen surgical strategies, you can lower...
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VASCULAR ANATOMY OF THE ANTERIOR ABDOMINAL WALL
Understanding anterior abdominal wall anatomy and the course of the deep inferior and superficial epigastric vessels is essential to the safe placement of secondary laparoscopic ports. epigastric vessels are the most commonly injured vessels during laparoscopic surgery.14,15 The inferior epigastric vessels originate at the external iliac, immediately above the inguinal ligament. They course medially to the round ligament and travel beneath the lateral third of the rectus abdominis muscle. Using anterior abdominal wall landmarks, the inferior epigastric artery can be identified midway between the anterior superior iliac spine and the pubic symphysis as it travels toward the umbilicus. The inferior epigastric artery also serves as the lateral boundary of Hesselbach’s triangle; the other two boundaries are the lateral edge of the rectus abdominis and the medial aspect of the inguinal ligament (FIGURE 2).13
As the inferior epigastric vessels course cranially, the distance from the midline
decreases. the average distance from the midline at the pubis is approximately
7.5 cm. At the umbilicus, it is approximately 4.6 cm.16,17 The most efficient way to identify laparoscopically the inferior epigastric vessel is to first identify the round ligament. This can be done using a uterine manipulator to deviate the uterus to the contralateral side. Then observe the course of the inferior epigastric vessel just medial to the entry of the round ligament into the inguinal canal. The laparoscopic surgeon can then follow the course of the inferior epigastric vessels to determine the safest location for placement of secondary ports. Transillumination can identify the superficial epigastric vessels, which course within the subcutaneous tissue of the anterior abdominal wall, although it doesn’t identify the deep inferior epigastric vessels that are beneath the lateral third of the rectus muscle. The superficial epigastric vessels follow a course similar to that of the deep inferior epigastric vessels, however, and can serve as a surrogate to guide safe placement of accessory ports.17
Landmarks of the anterior abdominal wall during laparoscopic visualization can also guide placement of secondary ports. The median umbilical fold, which is the peritoneal covering of the umbilical ligament/urachus, travels between the bladder and umbilicus in the midline anterior abdominal wall. Immediately lateral is the medial umbilical fold, which is the peritoneal covering of the obliterated umbilical artery, a branch of the superior vesical artery that comes off the anterior trunk of the internal iliac artery.2 The lateral umbilical folds are lateral to the medial umbilical fold and are the peritoneal covering of the deep inferior epigastric vessels. Identification of these anterior abdominal wall landmarks can assist the surgeon in placing lateral ports so as to avoid injury to these vessels.
Related article: How to avoid major vessel injury during gynecologic laparoscopy Michael Baggish, MD (Surgical Technique, August 2012)
MAJOR RETROPERITONEAL VESSELS
Although major retroperitoneal vessel injury is uncommon, occurring in only 0.3% to 1.0% of laparoscopic surgeries, it has the potential to be catastrophic.18 Therefore, an understanding of the surface anatomy of the major vessels is essential for midline port placement.
The abdominal aorta begins about 4 cm above the transpyloric line and extends to
2 cm inferior and to the left of the umbilicus, or, more accurately, to a point 2 cm left of the middle line on a line that passes through the highest points of the iliac crests. The point of termination of the abdominal aorta corresponds to the level of the fourth lumbar vertebra; a line drawn from it to a point midway between the anterior superior iliac spine and the symphysis pubis indicates the common and external iliac arteries. The common iliac is represented by the upper third of this line and the external iliac, by the remaining two-thirds.13
Related article: How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy Michael Baggish, MD (Surgical Technique, October 2012)
OBESITY AND LAPAROSCOPIC SURGERY
Over two-thirds of the US adult population is now classified as overweight or obese.19 Research has shown that, compared with abdominal hysterectomy, laparoscopic surgery entails a shorter hospital stay, less blood loss, and fewer abdominal wall and wound infections, which are important advantages for this particular population.20
Laparoscopic entry can be particularly challenging in the obese patient. A study by Hurd and colleagues showed that the mean umbilical location was 2.4 cm caudal to the bifurcation of the aorta in the overweight population and 2.9 cm caudal in the obese population.21 Because the bifurcation of the aorta is more cephalad to the umbilicus in overweight and obese patients, the laparoscopic surgeon can introduce the Veress needle at a steeper angle and more perpendicular to the abdominal wall than for a thinner patient (FIGURE 3).
