Peritoneal Access

access. Yeah, so this talk is sort of in two parts, just a general technical discussion about for laparoscopy, how we access the peritoneum and then at the end Liz is going to focus on in particular particular problem that we need to be aware of and and figure out how to address. So just uh get started for a 10-year-old with appendicitis, what does dissection clamp passage mean? That's what you do. Clamp passage? What is it? Your hemostat, when you pass your hemostat down through the umbilicus, Yeah. passage. pass a clamp. And then you take your clamp back out, and then you come back in with the the needle, right? I see. Yeah, yeah, yeah, yeah. Yeah. But I don't do that in a 10-year-old, by the way. That's only in while we're waiting for the answers to come through. I only do that in four year four week old pylorics. Once they're older, I do various needle. I do various needle. So you would have, you would have picked uh B. I would be. All right. B or if I do a Hassan, it depends. If it's an exterpative op- for a gallbladder, I'll do Hassan. So just polling the other people in the room Mark. B. So we're Just various needle through the fashion. That's what I do. In a 10-year-old. That's what we're talking about. What? A. Open dissection. Okay. You want to vote? No. How do you get What do you do? How do you get access? How do I get access? Yeah. Uh, I just do direct entry with the visualization in my adult. So optive view. Optive view. Okay. Does anyone else here use I did it for my first time uh last last week. Uh you use optive view quite a bit, right? Oh, okay. Okay. It's a good thing to use if you're not going through the umbilicus. Yeah. I did it through Palmer's point this past week. Yeah. Yeah. All right, well we'll keep But I Veressed first. I Veressed first to make my access safer. Understanding to distend the abdomen. Yeah, and then I did it. One option that you didn't have on there, and I'm shocked, is Sills. Okay. Or forget all that other stuff, would you have done a single sight approach, either the Sipes, which is the left bottom left picture, or a Tula, which is where you pull the umbilicus out of the umbilic, out of the appendix, out of the umbilicus and do an appendectomy on the outside. So put the scope in and do the rest. What? What do you say? Then put the scope in and do the rest of the appendectomy. So, uh I do it uh uh two different ways. So I'll do an operative laproscope through the umbilicus or put the camera in a graspers through the umbilicus, grab it, pull it up. But either way I do the It's classic Tula. The second one is the classic Tula. extra-extra corporeal single incision appendectomy. So you make Dan happy because you're the cheapest appendectomy in the hospital. Right. We don't know what percent of the total population voted for this, do we? Yeah, a lot of it depends on the body habitus, would you say? No, it depends on the surgeon. Okay. Surgeons are very committed to their one or the other. Okay. I would disagree with that, but that's okay. We've disagreed before. I want to hit on what Wit just said. So I will adjust what I do based on several different factors. Some say always do the same thing no matter what. I will if it's based on if they're large body habitus, I will do a three port appendectomy. I wouldn't even try single port. And and we've published papers on you can take the obe 90 90th percentile and above pediatric population and do Sipes appendectomy just as well as three trocar, so wound issues, all that stuff. It depends if you're doing an intra corporeal or an extra corporeal single port appendectomy. Not not if not if you have a wound protector, it's the same. In fact, it's better if you have a wound protector. That type of trocar we use has a plastic lining, so it it the pendex never touches anything as it comes in. Yeah. So this question was when it's time to pass your needle and your trocar, do you pay attention to the direction it's going? Do you try to go in and up toward the spleen and it up toward the right, and it up toward the left, straight up, or do you go straight down? I go up. I lift cuz I lift up on the umbilical stock, and then I poke superiorly. Superiorly in what direction? Do you mean left or right? Yeah. Superiorly straight up. Oh. That's the wrong answer for what I'm trying to get at. I know what you're getting at, but I still do that. All right. Any other comments about this? I oh I learned from Keith Jorgenson to go in and toward the spleen. Is that right? That's what I do. So. Well, that would that's a natural inclination for a right-handed person. For a right if you're a right-handed person stand on the right hand side of the in fact, even if I'm going to help a resident or fellow, I often times stand on the right to put the first trocar in. And then we move to to let them Well, I want to know I'm going to do it safest. Yeah, just depends on what side of the patient you're standing. Okay. So straight down that's not I I would say that's not really what we want. It's amazing, isn't it? Especially in some uh bigger obese people and teenagers, the distance between the posterior fashion, the umbilicus, and the aorta is about this far and intestines lying on top of that. So I think a lot of this is just how you insert your varis. I I generally do not go more than a millimeter. Like that, get that loud audible click. For me, it's that I have a loud varis needle because there are different brands of varis, and I like the ones that make a very loud audible click after you've passed the peritoneum. I agree with Todd, and I hope the needle is at the bottom now. So do I? Yep. And you have a helping helping a resident or fellow, and all of a sudden go, "Uh, they went in too far." You don't have that. That's why I do the Hassan technique. That's what I do, too. Yeah. Say that again, Mark. I'm sorry. But dart. put it like a dart. Yes, yes. Very close to the tip. All right. Uh, I think you you uh touched on the reasoning for not going straight down, but it's because in whatever direction you want to go to outside of straight down, you've got much more space to insert the the uh trocar and the cannula. Yes. And if you go straight down when you put your telescope in the first time, often times I notice people start looking around, did I poke a hole in something, right? You know, Scott Bollinger, my partner in Akron, made a quote once that I think is very true. All these things are great. All these things are important. The the key to success is that when you keep doing the same thing over and over and over again is how you minimize. It's when you start trying new tricks and techniques is when you end up getting injuries. So when you put your thing in a different location than you normally do, uh that's when you cause problem. If you do the exact same thing every single time, you usually are safer. But there are areas in the abdomen that are safer, right? If you're if you're poking straight down, the thing that's there, like Matt mentioned, the aorta, the most frightening thing, are the iliac, right? You get the iliac vein and you're going to have a really bad mess. And there's no iliac vein in the left upper quadrant. Yeah, but it Okay. I mean, I just I it's very rare that I'd be putting the varis needle in much more than a couple millimeters. If it is, I would do a Hassan. But I felt like if someone I couldn't if it's not a very thin patient that I could know that I'm just a couple millimeters in and hear the click, then I would do a Hassan. But the question is not just the varis, but it's the port, the trocar and the cannula. Oh, which direction you insert the trocar? Yes, both, yeah. Okay. And just to comment on your, if you do do it the same way every time, how do we then ever innovate? So I I guess there's migration to to what you would call a safer technique. I'm talking about the cases I've heard about people getting injuries is when they have done things um like can insert them in the left insert them in different places where they're not used to and know the feel of it um when they've got injury. If you're trying to modify the technique to make it safer, like which angle you pointed in, I think that that's probably not going to cause much harm. If you use the sheathed Varis needle approach, do you insufflate before passing the trocar? I don't use sheathed. I. You don't use a sh- sheath? Okay. We still use step trocars. Not first. Well we we we're not using the step anymore. Okay. But the with the open Hassan, I would just put the sheath in without the varis and then put the cannula through the sheath. And not before and then insufflate. Yes. So if you do a Hassan, you can either make the incision on top of the umbilicus, right through the umbilicus, or under the umbilicus. At our place, we generally make a vertical incision right through the umbilicus, except in the neonate now. And what are you doing in the neonate? Well, we're I I try to make an infra umbilical incision. Okay. Where is what do you do? Through the belly button, see the peritoneum and see that you're actually in the abdomen. So you so you your skin incision through the umbilicus. Through the umbilicus? Skin incision through the umbilicus. Then what? And and through the peritoneum and then put the sheath in. Wait. So you're cutting down through the you're you're assuming that And in the babies. in the babies. So in old if if this is some if this is 16-year-old. yeah, then they they're getting a Sills. We don't we do almost anything. Well, how do you make it different. How do you get how do you get access to your Sills? How do you We make an incision through the umbilicus. It's open. Yeah. real. It's a mini linea alba midline incision. It's a DPL incision, right? When we were doing diagnostic peritoneal lavage back a thousand years ago. Yeah. It's the same thing. No one knew what that was. Right. So The dinosaurs are roaming the earth. Okay. Now we're focusing on specific patients. So a two-day old with doadinal atresia, the same question we asked at the start about how you would get into the peritoneum. Uh duadinal atresia I'll do an infra umbilical incision because it's going to it's going to be a newborn with a wet umbilicus and you really need to be careful you don't canulate the uh umbilical vein. And then how do you, so you make an infra umbilical skin incision and then how do you get into the belly? I put a varis needle through. Without a sheath. Without a sheath. Yeah, you know I I I think that uh the those the step trocars are not designed to be placed with the sheath in because it's a big step off, a big change in diameter, and I really worry worry that you'll deflect the abdominal wall and injure something. So I think if you use a step, you should always put the varis needle in first, safely insufflate, then put the varis needle with the sheath in to insert your sheath. I do the same. I've never heard of that. Yeah, I do the same. It was a. Just never heard of that. Yeah, it's a much more it goes much more slick and smooth when you put the varis without the sheath. The sheath adds that little obstruction to it. Huh? uh that's why I won't use that trocar because I can't stand that step off. Now I've never tried just putting in the varis first, cuz that's what I do anyway. Varis first. Yeah. So, Mark, a real technical point here. If we if we can get in the weeds a little bit, yeah. do you think you can make that infra umbilical incision and still come at an an angle with your Varis needle that you could get the vein? Or do you or or now we're back to going straight down and you feel like you're centimeter below the center of the belly button. If you're not going straight down. So and with a little baby, you can actually, something remember Keith used to do this all the time, you can grab the umbilicus and just lift it up. If you want to use do the towel clamp trick, you can. But I think that if you come you remember the umbilical vein is going to come up through the center of the umbilicus. If you go below, you shouldn't be hitting that orifice. I think the danger isn't that you're going to The danger isn't that you're going to, you know, somehow go in the belly and then canulate the umbilical vein. I think the danger is that you're just going to go through the orifice or the the obliterated orifice of the umbilical vein, which is at the base of the umbilicus. So if you go below that, you should be, in theory, outside of the umbilical vein. So um along this is what's interesting, I'm thinking now, what it what are the risks that get you into the umbilical vein, which we're going to talk about. But that's what I do exactly every time, and this is why I go superior. So I grab the umbilical stock with a cooker or snap, lift it straight up, and I go try to go perpendicular to now the fascia instead of flat is like this, and I go perpendicular to that every single time. And that and that's what I do. You do the same. Yeah, I do the same. With just a varis, without the sheet. Got it. Yeah. Yeah. High five on that. Okay. We're on the highlight clip. Oh, yeah. 50 50% don't need to worry about what we're talking about. Right. because they do it okay. But see, I worry about I worry that a quarter do dissection and clamp passage into the peritoneum, and that a varies because I worry that you can open up that that open up the umbilical vein. But I think for those that do that, you just need to be careful and know that you're popping into the peritoneum. All right. Well, I think the the important point I think Liz may get into this a little bit more is that at least from my knowledge until about a year ago, I didn't know about any about this potential complication. And maybe that's by ignorance. That is of of either canulating the umbilical vein or getting CO2 in the unbilical vein. You're going to talk about this. And and so to me it's it's it's really interesting that we've been doing this for over 20 years and this devastating complication is really just coming to light or or just becoming knowledgeable to to us. So so what Dr. Holcomb is referring to, just to say it because Dr. Byerly is going to go into depth on this, is that in the last year, there has been a lot of recent discussion among some of our colleagues uh who have seen a lot of they've heard of a lot of cases or seen cases of when the access was made, there was entry and air entry into the umbilical veins, causing an air embolism. And that's what we're. A CO2 embolism. A CO2 or or air, uh which is a big problem and that's what we're going to that's what I'm I'm stealing Dr. Byerly's thunder, but that's essentially a big reason of why we're talking about this right now. Or air. That's where we're going. And Wit's point was that why is it that I have never heard of it before this year? You've never heard of it before this year and now all of a sudden everyone's talking about it. So. It was a hot topic at Ipeg. That's that's where it came up. Dr. Rothen presented it. Right. 12 cases. But why did but we didn't hear this from Steve until about a year year and a half ago when he started talking about it. Before that I'd never. I heard of a case two or three years ago was the first one and I've heard of three or four five more since then and he's he says 15 that he knows about. Okay, right. Yeah. All right. We're getting cuz we're way behind now. Okay, I'm sorry. We'll hurry ahead. Uh how about a four week old with pyloric stenosis? The same question about access. Anything different here? Two day versus a four week. Cord's a little better. So I'm D here. But I'm I'm not D sort of. I am I am dissection, pass the hemostat and then put a port in. Okay, you make the whole big enough to just drop the port in. Yeah. Okay. So although there's no prospective randomized trial on this, at what age do we think we don't have to worry about the umbilical vein? Yeah, the umbilical vein being problematic. It's a great question. Steve says two months. I don't know where he got that. I can't see where he got it. Out of his back pocket. Sorry, Steve. Well, look at that. That's amazing there. Sort of a four-way split. Interesting. All right, here's the case. As you access the peritoneum for pyloromyotomy in a four week old male with pyloric stenosis, the patient becomes bradycardic, hypotensive, and drops his entitled CO2. You you immediately worry about. I hope this answer is straightforward. So just a 30,000 foot CO2 embolization is a rare event. It happens in adults, but it's not usually the umbilical vein. It's just like can you imagine a very vary near the umbilicus and somehow you get just into the Venus system and blow CO2? Uh clinically significant embolization results in a mortality of 25%. Some people have discussed uh transesophageal echo urgently to try to help figure out what's going on. Uh treatment immediate treatment options that people try are immediately desufflate, put yourself in trendelenburg, a central Venus line to suck out the gas and I know of several cases who have gone on ECMO emergently and at the start of the pyloromyotomy. So be aware, don't we don't really know the incidence in babies, but the impression is that it's real and deadly. Pediatric surgeons should be working on a technique that lowers the incidence and thus the reason for these discussions. Uh I believe now when I put I use a sheath, but I always put the trocar in before I insufflate, look with the telescope, make sure I'm in the peritoneum, then then put on the insufflation. But I have to say Steve Rothenberg, who's worried about this, believes that you can get CO2 embolization without necessarily just having your needle or trocar in the vein. He believes somehow there's a way to damage the vein on the way in and insufflate into the peritoneum like you're supposed to, but have the CO2 rush back up and go through the vein. And so the open technique may be the safer way, uh what Wit is described as the inferior Hassan. Well, so uh and I don't know this information, but does anyone have any impression of is is this occurring with a variety of techniques or is it maybe one technique that's happening? Is anybody I don't know the answer to that. Well, again, Steve, because he and I have discussed this a lot, would say anybody who's not doing an infra umbilical incision to doing a Hassan approach straight down, all the other techniques are at risk, is his opinion. Right. And I don't think we know what's right. Okay.