Letters and emails
Laparoscopic entry after previous surgery
It is a great pity that Jonathan Frappell did not take the opportunity in his otherwise excellent overview to recommend that laparoscopic entry in any women with a history of a lower abdominal laparotomy, be it a low transverse or vertical incision, should be via Palmer's point. In failing to do so, he perpetuated the indecisive line taken in the RCOG guideline on Preventing Entry-related Gynaecological Laparoscopic Injuries he refers to, and which states: “The umbilicus may not, therefore, be the most appropriate site for primary trocar insertion following previous abdominal surgery”. What the RCOG document should have said is that: the umbilicus is not, therefore, the most appropriate site for primary trocar insertion following previous abdominal surgery (and should not be used – my own words).
Why? If one in two women have adhesions under the umbilicus after a midline laparotomy and one in four after a low transverse laparotomy, then surely it is extremely unwise to insert a Veress needle at the umbilicus in either situation? It is equally unwise to use Hasson's open entry technique as it is no safer then blind entry when bowel is adherent under the umbilicus. The correct strategy, unless there is an obvious contraindication which in my experience is extremely rare, is to use Palmer's point.
It is not clear to me why many gynaecologists are reluctant to use Palmer's point for laparoscopic entry. We use Palmer's point liberally in our practice, employing it in about one in three of our patients. Palmer's point is not only appropriate when there is a history of laparotomy but also in women with large pelvic masses such as sizeable fibroids and ovarian cysts. It is certainly worth learning. On a lesser note, I believe the figure showing Palmer's point is misleading – Palmer's point is 3 cm below the rib cage, so must be considerably lower than the mark in the photo.
I thank Adam Magos for his thoughtful observations on my paper. We are agreed that the single most important ‘take home message’ is to stay well away from surgical scars when choosing the site of primary entry. For any patient with a mid-line laparotomy scar therefore, this means using a site other than the umbilicus, even if using the Hasson open entry technique, as I made clear in the article. I agree that for the majority of such patients closed entry techniques at Palmer's point would be the method of choice.
In patients with a Pfannenstiel incision, however, I feel that the evidence is not strong enough to mandate use of Palmer's point entry in every case. Audebert and Gomel's paper on the incidence of adhesions at the umbilicus showed a 19.8% risk of umbilical adhesions following a previous Pfannenstiel incision, but only a 6.87% risk of “severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar”. In practice, we know that in the majority of cases these will be omental adhesions attached to the underside of the Pfannenstiel incision, a little way below the umbilicus. I think it is reasonable therefore to use Hasson open entry at the umbilicus in such patients. That having been said, I agree with Adam that individual surgeons will tend to use Palmer's point much more frequently as their own familiarity and confidence with the technique develops.
The reason why many gynaecologists feel reluctant to use Palmer's point, I believe, is that they feel uncomfortable in the unfamiliar territory of the upper abdomen. Moreover, it can be more difficult to penetrate the peritoneum with the Veress needle than it is at the umbilicus. To overcome this problem some surgeons advocate using a subcostal approach (my own preference) or even going through the lowest (9th) intercostal space.[2, 3] Hence, the precise position of Palmer's point for any individual surgeon may vary from the original description of 3 cm below the costal margin. In Audebert and Gomel's series of over 800 patients, in three cases with previous surgery in the left upper quadrant they safely inserted the Veress needle via a right subcostal approach.