Short notes on the open Hasson technique used to gain entry to the abdomen for laparoscopy and insertion of the first (umbilical port - 10mm)
Two main methods, both approved, safe and widely used.
INDICATION: For infraumblical entry in diagnostic laparoscopy, lap appendicectomy, lap cholecystectomy, in a virgin abdomen or no surgery near entry site, no pervious peritonitis, no hernia. If any of the above consider alternative entry site. If bowel obstruction present consider a mini-laparotomy.
For both methods you may choose to infiltrate local anaethesia at the start to the skin. Some do this at the end.
METHOD 1 - Transverse Incision:
Step 1: Under GA, scrub, prep, drape
Step 2: Position (supine or lithotomy based on procedure)
Step 3: Littlewood's to invert and grasp umbilicus and lift up. Might have to clean umbilicus with a clip and swab further as inevitably one encounters some material that the initial prep will have missed
Step 4: Transverse incision infra-umbiilically along the crease which is produced when you lift up on the Littlewood. No longer than 1cm - 1.5cm. Use a 15-blade (stab incsion).
Step 5: Use a second littlewoods (or remove one from umbilicus) and direct inferior medially and grasp the cicatrix (umbilical stalk). Lift up. Give a Langenbeck to the assistant to retract the inferior edge of the wound
Step 6: Dissect down close to the cicatrix in the midline until the vertical fibres of the anterior sheath are seen using toothed forceps and Mcindos dissecting scissors.
Depending of the body habitus of the patient the depth at which the cicatrix/sheath junction encountered will vary. Therefore keep repositioning the Littlewood along the cicatrix as you go deeper to allow better vision and retraction. Insrtuct the assistance as to depth and intensity of retraction
Step 7: Use the knife to gently incise vertically, few fibres at a time along the sheath, 0.5cm along anterior sheath and 0.5cm on the umbilical stalk.
Step 8: Carefully incise fibres of the sheath until clear. In a mjority you will reach peritoneum. A finger may be used to bluntly go through the remaining layers. Some use an artery forcep (clip) to do this. Ensure the clip is closed and NEVER open and close inside the abdomen.
Lift up the Littlewoods still attached to Cicatrix as you do this.
Step 8B: If tough tissue or a further layer is encountered which the finger will not protrude, consider applying a second littlewood to the lower edge of the incision on the sheath. Use a clip to grasp the layer and incise between two clips using scissors to gain entry into abdomen.
Step 9: Once inside the abdomen do a finger sweep to ensure no adhesions or any other obvious abnormality
Step 10: Provided safe to proceed some opt to insert a stitch at the start. In the past before ballon/self sealing ports it was essential to do this at the start to ensure adequate seal for the pneumoperitoneum. Use a vicryl or PDS stitch on a J-shaped needle or 3/4 curved needle. Insert a purse-string suture or vertical matress suture (i.e box suture)
Step 11: Ensure hole is still patent with finger and now insert the blunt camera port and remove trochar. Remove littlewoods and retractors applied. Apply relevant seal (e.g. inflate balloon, secure seal) or secure suture ends to port edges (notches available on all ports for this).
Step 12: Before inflating the pneumoperitoneum insert the camera (white balanced, anti-mist applied) to the port to see if ometal fat/small bowel seen. If this is not the case go back to Step 8B. Other wise inflate pneumoperitonem (10-12mmHg) and low flow initially.
Step 13: Enter abdomen. If safe to proceed continue with procedure and insertion of the other ports
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METHOD 2 - Vertical Incision:
Step 1: Under GA, scrub, prep, drape
Step 2: Position (supine or lithotomy based on procedure)
Step 3: Vertical incision infra-umbiilically along the midline. No longer than 1cm - 1.5cm in length. Use 15-blade (stab incsion).
Step 4: Use Langenbeck's (or S-Shaped retractors) to perform blunt dissection of subcutaneous tissue until the white sheath is seen. Alternatively you may use dissecting scissors to separate tissue and dissect any tissue. Usually division with retractors is adequate. Some strenght and force may be required especially if the patient has a large body habitus.
Step 5: When you can see the sheath, ensure you clear a space around the sheath using the retractors. You may have to use scissors at times.
Step 6: Use Littlewoods and grab the sheath. Use another littlewood and apply it inferiorly.
Step 7: Replace the first Littlewood until a good volume of sheath has been grasped between the two little woods. The two should be < 1cm apart.
Step 8: Use the knife to gently incise horizontally, few fibres at a time along the sheath between the two Littlewoods(<1cm in length).
Step 9: Once you are through the fibres of the sheath reposition the Littlewoods one after the other to grasp the cut edges of the sheath. Use a forceps to hold the edges before you let go of the tissue held by the Littlewoods.
Step 10: In a mjority you will reach peritoneum. A finger may be used to bluntly go through the remaining layers. Some use an artery forcep (clip) to do this. Ensure the clip is closed and NEVER open and close inside the abdomen.
Lift up the Littlewoods still attached to Cicatrix as you do this.
Step 8B: If tough tissue or a further layer is encountered which the finger will not protrude, consider applying a second littlewood to the lower edge of the incision on the sheath. Use a clip to grasp the layer and incise between two clips using scissors to gain entry into abdomen.
Step 9: Once inside the abdomen do a finger sweep to ensure no adhesions or any other obvious abnormality
Step 10: Provided safe to proceed some opt to insert a stitch at the start. In the past before ballon/self sealing ports it was essential to do this at the start to ensure adequate seal for the pneumoperitoneum. Use a vicryl or PDS stitch on a J-shaped needle or a 3/4 curved needle. Insert a purse-string suture or vertical matress suture (i.e box suture)
Step 11: Ensure hole is still patent with finger and now insert the blunt camera port and remove trochar. Remove littlewoods and retractors applied. Apply relevant seal (e.g. inflate balloon, secure seal) or secure suture ends to port edges (notches available on all ports for this).
Step 12: Before inflating the pneumoperitoneum insert the camera (white balanced, anti-mist applied) to the port to see if ometal fat/small bowel seen. If this is not the case go back to Step 8B. Other wise inflate pneumoperitonem (10-12mmHg) and low flow initially.
Step 13: Enter abdomen. If safe to proceed continue with procedure and insertion of the other ports
NB some bleeding may be encountered on entry from the sheath. The tamponade from the port and/or suture will control this. Remeber to inspect this on closure.
Author:
Mr Kasun Wanigasooriya MBCHB, MRCS | Speciality:
Surgical Procedures | Date Added:
30/06/2014
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