Email: elnashar53@hotmail.com Aboubakr Elnashar

Importance

1. Placement of the primary trocars through the anterior

abdominal wall:

- Anterior abdominal wall anatomy

- Location of the retroperitoneal vessels

2. Placement of the secondary trocars :

- Abdominal wall vasculature

3. Manipulation of the peritoneal surfaces or

retroperitoneal area

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Anterior abdominal wall thickness

-Immediately below the umbilicus:

Skin

Subcutaneous tissue

Anterior rectus sheath

Rectus abdominous muscle

Posterior rectus sheath

Peritoneum

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-At the base of the umbilicus:

Skin,

SC adipose tissue,

fascia (union of ant & post rectus sheathes),

preperitoneal adipose tissue,

peritoneum

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-Intraumiblical:

Skin is attached to fascia (the anterior rectus sheath,

which is attached to the posterior rectus sheath) &

peritoneum.

No subcutaneous tissue or rectus abdominis muscle

•The thinnest part of the anterior abdominal wall

•Vertical intraumblical incision:

Thinnest part of the anterior abdominal wall

Improves the cosmetic results

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Resistance from the fascial layer

causes the inner sleeve hub to

move up

Once the VN has completely penetrated the fascial layer, the inner

sleeve moves back to its original position & produces a pop

caused by the inner sleeve striking the outer hub

The inner sleeve moves back

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Tenting of the

peritoneum

will move the

inner sleeve

upward

again

After the needle is through the

peritoneum, the inner sleeve retracts

back to its original position, producing a

second pop

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Increase abdominal wall thickness with

increase in weight

•Angle of placement of the Verres needle or trocar at the

base of the umbilicus:

-Thin (BMI <25 Kg/m2): 45º

-Normal wt (BMI 25-30 Kg/m2): 60 º

-Obese (BMI >30 Kg/m2): 75º

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Anterior abdominal wall vessels

Superficial vessels: Superficial epigastric a

Superficial circumferential iliac a

Branchs of inguinal a, course bilaterally through the SC

tissue, branching as they proceed toward the head of

the patient

Deep vessels: Inferior epigastric a

Branch of external iliac a, near the inguinal canal

courses along the peritoneum cephalad & medially until

it dives deeply into the rectus muscle, midway between

the symphysis & the umbilicus.

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Methods of localization

1. Superficial vessels: Transillumination:

Good for superficial vessels in thin patients

Of little value for the deep vessels which run beneath or

within the rectus muscle

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2. Deep vessels:

a. Abdominal localization:

Inferior epigastric: 3 cm above the symphysis &

5.5 cm from the midline

So, Safe location for trocar: 8 cm above the symphysis &

8 cm from the midline is a

b. Laparoscopic visualization: Origin: where the round ligament enters the inguinal

canal.

Runs lateral to the medial umbilical fold (oblitrated

umbilical a)

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3. External iliac vessels:

Often lie directly beneath this location

So,

Trocars must be placed

at 45º toward the midline

under direct visulization

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Retroperitoneal Structures

Bladder

The dome of the bladder is few cm s below the

symphysis

How to minimize risk of injury?

1. Routine catheterization

2. Previous low transverse skin incision: Put the

trocar above

3. Previous midline incision:

Put the trocar slightly off the mid line &

at least 3-4 cm above the symphysis Aboubakr Elnashar

Ureter

How to reduce the risk of ureteral injury during

laparoscopy?

Awareness of its general location within the

retroperitoneal space & its relationship to other

major landmarks

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Anatomy: 30 cm long

Abdominal part: from renal pelvis to the pelvic

brim

Courses along the anterior & medial aspect of

the psoas muscle until it crosses over the

common iliac vessels, approximately 1.5 cm

above the bifurcation of the internal & external

iliac vessels.

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Pelvic part: from pelvic brim till the bladder

It courses anterior to the internal iliac vessels,

crossing the obturator muscle & turning medial at the

level of the ischial spines.

It passes lateral & superior to the the uterosacral

ligaments & courses below the uterine vessels.

It runs obliquely through the cardinal ligament,

ventral to the anterior vaginal fornix

It angles upwards (forming a J) & inserts into the

bladder trigone

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How to identify the ureter during laparoscopy?

1. Ureter can often be identified through the

semitransparent peritoneum in thin patient. It is

best to identify the ureter at the bifurcation of

the common iliac vessels & trace it into the

pelvis by observing its peristaltic activity.

2. Indigo carmine or methylene blue IV to color

the urine.

3. Opening the retroperitoneal space

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Opening the retroperitoneal space: as in laparotomy

-The initial incision is made either by dividing the

round ligament or by incising the peritoneum above

the psoas muscle.

--The pararectal & paravesical spaces are then

carefully developed & the ureter identified coursing

along the medial leaf of the broad ligament

peritoneum at the level of the bifurcation of the iliac

vessels

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Laparoscopic procedures in which the ureter can

be injured:

Procedures requiring

ablation,

lysis of adhesions at the pelvic side wall, or

extensive retroperitoneal dissection or

division of the infundibulopelvic ligament

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•Treatment of endometriosis

E. Commonly involves the uterosacral ligament & the

peritoneum between the uterosacral & the broad

ligament. Because the ureter is in intimate contact with

the peritoneum in this area , it is at risk for injury during

either laser ablation or electrocautery

•During LAVH: Common sites of injury:

1. Near cardinal ligament, at the time of uterine vessel

transection

2. Near infundibulopelvic ligament, during ligation of of

the ovarian vessels.

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Diagnosis of ureteral injury

1.Observing for leakage after IV indigo

carmine

2.Intraoperative retrograde pyelogram

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Iliac vessels

1. External iliac vessels, with the artery running

lateral to the vein, course along the pelvic side wall &

exit the pelvis below the inguinal ligament.

The round ligament disappears into the peritoneum as it

enters the inguinal canal immediately above the

external iliac vessels. This consistent relationship is a

useful anatomic landmark for locating these vessels

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2. Internal iliac vessels:

course downward into the pelvis along with the ureter.

Both the internal & the external iliac vessels can

sometimes be identified through the semitransparent

peritoneum.

In presence of adhesions, the vessels may not be

visible. If extensive dissection is required, the

retroperitoneal space should be opened to avoid

injury of major vessels & the ureter.

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