Use of Palmer’s Point in Creation of Pneumoperitoneum in Patients of Previous Abdominal Surgeries and To Check Efficacy of the Visceral Slide Technique for Detection of Abdominal Wall Adhesions

ABSTRACT

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.