PMID: 10498021

Issn Print: 1040-872X

Publication Date: 1999/08/01


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The unkindest cut of all: when a small laparoscopy incision has to be converted to a laparotomy

Chris Sutton

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The advantages of laparoscopic surgery in terms of short hospital stay and rapid recovery are well known, but increasingly patients are attracted by the small scars associated with the minimal access approach. Although surgeons themselves are all too well aware that surgical complications are an inescapable fact of life, our patients find this less easy to accept and anything that alters their anticipated expectation of the operation will almost certainly result in an attempt to achieve redress by means of litigation. If damage to the bowel or bladder occurs during a laparotomy, the damage can easily be repaired through the same incision and the length of stay in hospital is unlikely to be altered. This is in marked contrast to an accident occurring during a laparoscopy, because instead of a series of small incisions which the patient has been led to expect, she wakes up with a large incision which is often made by a surgeon in the midline, which can be particularly disfiguring; even worse, there may be a temporary defunctioning colostomy. Although there may be no permanent harm to health, patients are increasingly advised by their lawyers to emphasize the mental upset caused by the emotional stress of dealing with the complication and it is a relatively easy matter to find some psychologist who is willing to give support to a claim of post-traumatic stress disorder.
In recent years, with the increasing sophistication of three chip cameras, high resolution monitors and the superb optics provided by the modern laparoscope, the view obtained during surgery is often better than that provided at an open operation. Electrosurgical generators and various protective devices to avoid capacitative coupling have led to a diminution in electro-surgical accidents. In addition, increased training of surgeons means that intra-operative complications are becoming less common, so the 'unkindest cut of all' is the first entry with the Veress needle or sharp primary trocar. This is essentially a blind procedure, because there is no way of knowing whether bowel may be stuck to the anterior abdominal wall in the region of the umbilicus.
There are several ways to circumvent this problem. In the early 1970s Semm [1] described his 'z-step' technique of introduction, whereby the sharp primary trocar was displaced laterally once it had pierced the posterior rectus fascia and an attempt was made to identify a clear window in the peritoneum, because the reflectance of the light from this surface indicated whether or not bowel was adherent underneath the peritoneum. In practice, it was not quite this simple and quite often the trocar had already entered the peritoneum before this observation could be made. In obese patients with a peritoneum laden with adipose tissue, this technique was unhelpful. Raoul Palmer [2], one of the great fathers of laparoscopic surgery, described first entry at 'Palmer's point', which lies in the mid-axillary line, just underneath the ninth intercostal rib. This is an area that is traditionally free of adhesions, although clearly one must check to make sure there is no splenomegaly before inserting a trocar at this site. This site of entry is certainly recommended in any patient who has a mid-line laparotomy scar from previous surgery. Usually a small 5 mm laparoscope, or even an optical Veress needle, is inserted here and the area of the umbilicus is inspected to check whether or not adhesions are present. If they are, a second port can be inserted in the left iliac fossa and adhesions cleared with laparoscopic scissors.

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