Laparoscopic Entry Techniques

 

Abstract

Background

Laparoscopy is a very common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity.

Objectives

The objective of this study was to compare the different laparoscopic entry techniques in terms of their influence on intra-operative and post-operative complications.

Search methods

This review has drawn on the search strategy developed by the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched through to July, 2007.

Selection criteria

Randomised controlled trials were included when one laparoscopic primary-port-entry technique was compared with another.

Data collection and analysis

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto version) with their 95% confidence intervals.

Main results

The 17 included randomised controlled trials concerned 3,040 individuals undergoing laparoscopy. Overall there was no evidence of advantage using any single technique in terms of preventing major complications. However, there were two advantages with direct-trocar entry when compared with Veress-Needle entry, in terms of avoiding extraperitoneal insufflation (OR 0.06, 95%CI 0.02, 0.23) and failed entry (OR 0.22, 95%CI 0.08, 0.56). There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (OR 0.06, 95%CI 0.01, 0.46). Finally, there was an advantage of not lifting the abdominal wall before Veress-Needle insertion when compared to lifting in terms of failed entry without an increase in the complication rate (OR 5.17, 95%CI 2.24, 11.90). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index, who often had unusually high complication rates.

Authors' conclusions

On the basis of evidence investigated in this review, there appears to be no evidence of benefit in terms of safety of one technique over another. However, the included studies are small and cannot be used to confirm safety of any particular technique.

 

Plain language summary

Laparoscopic Entry Techniques

Laparoscopy enables direct visualisation of the pelvic and abdominal organs with a special telescope called a laparoscope so key-hole surgery can be performed as indicated. To perform laparoscopy, gas is inserted into the abdomen. Although usually safe, a small minority of patients experience life-threatening complications, including injuries to the blood vessels (0.9 per 1000 procedures) and the bowel (1.8 per 1000 procedures). These complications often occur when the laparoscope is passed through the abdominal wall for the first step of the procedure, using specialised instruments to insert the gas. Different doctors use different specialised instruments and techniques. This review found no evidence that any single technique or specialised instrument used to enter the abdomen helped to prevent life-threatening complications. More research is required.

 

摘要

背景

腹腔鏡置入技術

在婦科，腹腔鏡是一個很普遍的手術。併發症常與腹腔鏡置入有關。威脅生命的併發症包括對腸道、膀胱、腹部大血管, 和腹部前壁血管的傷害。其它相較不嚴重的併發症亦有可能發生, 譬如術後感染, 皮下氣腫和腹腔外充氣。 目前對於腹腔鏡的置入並沒有一個公認的最佳方式。

目標

這項研究將比較不同的腹腔鏡置入方式對術中或術後併發症的影響。

搜尋策略

本篇所使用的搜尋方式是根據 enstrual Disorders and Subfertility Group 所使用的搜尋技巧。除此之外，也搜尋了 MEDLINE及EMBASE至 007年7月的資料庫。

選擇標準

納入比較的隨機對照試驗包括當一個主要的腹腔鏡置入技術與其他的技術比較

資料收集與分析

資料由第一二位作者獨立地提取了。看法差異由第四位作者登記和解決。而結果是以位於95% 信賴區間的勝算比(odds ratio)(Peto version)來呈現。

主要結論

共搜尋到17個隨機對照試驗,總計3040人接受腹腔鏡手術。整體而言，並沒有證據顯示任何一個腹腔鏡置入的技巧可以避免併發症。然而，直接導管置入法(directtrocar entry)有兩項優於導氣針氣腹法 (VeressNeedle entry): 避免腹腔外充氣(OR 0.06,95% CI 0.02, 0.23)及置入失敗(OR 0.22, 95% CI 0.08, 0.56). 此外在導管穿刺處的出血方面,使用radially expanding access system (STEP)的置入方式也明顯優於傳統方式 (OR　0.06, 95% CI 0.01, 0.46)。最後，置入導氣針導管時不將腹部提高相較於提高在放置失敗率上較有優勢(OR 5.17, 95% CI 2.24, 11.90)但不會增加併發症發生率。但是，這些研究侷限與數量較小，且將一些曾經開過刀或BMI較高的病人排除在外，而這些病人併發症的發生率是相當高的。

作者結論

根據這些文獻現有的證據顯示，並沒有一個腹腔鏡置入方法是最有利的。但是，現有的研究規模較小，以至於無法確認任何一種技巧的安全性。

翻譯人

本摘要由高雄醫學大學附設醫院張慧名翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

腹腔鏡手術是利用像鑰題孔般大小的特殊鏡頭,進入腹內探視骨盆腔及腹腔內的器官。在使用腹腔鏡時，腹腔內會灌入氣體。這個步驟通常是安全的，但是有少數病人可能會有危及生命的併發症，例如大血管損傷(0.9 per 1000 procedures)和腸道的損傷(1.8 per 1000)。這些併發症通常是在灌氣體的第一步驟時發生。每個醫師用的技巧皆不相同。本篇研究發現並沒有一個腹腔鏡置入技巧對於避免危及生命的併發症是較好的。更多的研究是需要的。