RÉSUMÉ
In patients with history of previous abdominal surgery, creation of pneumoperitoneum during laparoscopicprocedure involves risk of complications as there is association of underlying adhesions at the umbilicus site.Palmer’s point is alternative site of primary port insertion. For creating pneumoperitoneum, visceral slidetechnique is used to detect the movement of viscera immediately deep to the abdominal wall. This techniqueis reliable in identifying adhesion-free areas of the abdominal wall. This study was undertaken to evaluate useof Palmer’s point in creation of pneumoperitoneum in patients of previous abdominal surgeries and to checkthe efficacy of the visceral slide technique for detection of umbilical adhesions in these patients. This one-yearstudy was conducted on 30 patients with previous history of abdominal surgery in the Government MedicalCollege, Jammu. Visceral slide test was conducted using a real time ultrasonography machine with a 7.5 MHzabdominal transducer placed in a sagittal plane at the umbilicus and the ultrasound scan focused on theinfraumbilical region between the anterior abdominal wall and the aortocaval complex. A normal visceral slide(positive test) is movement of the viscera more than 1 cm. An abnormal visceral slide (negative test) is definedas movement of the viscera less than 1 cm. At the end of the surgery, intra-operative, early and late complicationswere evaluated. Adhesions under the umbilicus were present and absent in 15 (50%) patients each. Thevisceral slide technique was negative in 9 (30%) and positive in 21 (70%) patients. Sensitivity, specificity,positive predictive value, negative predictive value and accuracy of visceral slide technique was 60%, 100%,100%, 72% and 70% respectively. Definitive evidence of the efficacy of Palmer’s point in creation ofpneumoperitoneum could not be established due to the small sample size and patients with limited spectrum ofabdominal surgeries. Further studies in the form of multicenter randomized control trials are needed to verifythe utility of Palmer’s point for creation of pneumoperitoneum and to evaluate the role of visceral slidetechnique in diagnosing intra-abdominal adhesions preoperatively.
RÉSUMÉ
RESUMEN Objetivos: El objetivo del estudio es observar los beneficios de la entrada laparoscópica con trocar para la óptica, tras la insuflación previa con aguja de Veress en punto de Palmer, hasta conseguir una presión intraabdominal de 25 mmHg. Material y método: Estudio prospectivo de 115 cirugías laparoscópicas realizadas con la técnica anteriormente descrita, por el mismo equipo quirúrgico; de julio de 2014 a marzo de 2018, en el Departamento de Ginecología del Hospital General Santa María del Puerto. Resultados: El tiempo medio de las maniobras de acceso fue de 175 segundos. En el 84.3 % de las ocasiones, el acceso a la cavidad abdominal se consiguió en el primer intento. Sólo en dos ocasiones (1.7%), fue necesario cambiar la técnica de acceso. No se objetivó ninguna complicación o efecto adverso en el 96.5% de las cirugías. En dos pacientes (1.7%) se produjo un enfisema subcutáneo, en una ocasión un enfisema epiploico (0.9%) y en una paciente (0.9%), se objetivó una ligera intolerancia anestésica durante la realización del neumoperitoneo. No se registró durante el estudio ninguna complicación mayor asociada a las maniobras de acceso. Conclusiones: La entrada con presiones altas intraabdominales tras insuflación con aguja de Veress en punto de Palmer, es una técnica segura y reproducible para evitar complicaciones mayores, durante las maniobras de acceso a cavidad abdominal. Además, esta técnica no produce efectos adversos anestésicos relevantes secundarios a las altas presiones en pacientes sanas, debido al escaso tiempo durante el que se mantienen las mismas.
ABSTRACT Objectives: The aim of the study is to observe the benefits of laparoscopic trocar entry for optics, after previous insufflation with Veress needle at Palmer's point, until an intra-abdominal pressure of 25 mmHg is achieved. Material and method: Prospective study of 115 laparoscopic surgeries performed with the previously described technique, by the same surgical team; from July 2014 to March 2018, in the Department of Gynecology of the Hospital General Santa María del Puerto. Results: The average time of access maneuvers was 175 seconds. In 84.3% of the cases, access to the abdominal cavity was achieved on the first attempt. Only on two occasions (1.7%), it was necessary to change the access technique. No complication or adverse effect was found in 96.5% of the surgeries. Subcutaneous emphysema (1.7%) occurred in two patients, epiploic emphysema (0.9%) and in one patient (0.9%), a slight anesthetic intolerance was observed during the pneumoperitoneum. No major complications associated with the access maneuvers were recorded during the study. Conclusions: The entry with high intra-abdominal pressures after insufflation with Veress needle at Palmer's point, is a safe and reproducible technique to avoid major complications, during maneuvers of access to the abdominal cavity. In addition, this technique does not produce relevant adverse anesthetic effects secondary to high pressures in healthy patients, due to the short time during which they remain.