Lifting of the umbilicus for the installation of pneumoperitoneum with the Veress needle increases the distance to the retroperitoneal and intraperitoneal structures.

BACKGROUND: In laparoscopy, 50% of all complications occur during establishment of the pneumoperitoneum. Elevation of the fascia is recommended for the Veress needle approach, although the benefit has not been proved to date. This study aimed to evaluate the intraabdominal changes during lifting of the fascia with regard to the distance from the fascia to the retroperitoneal vessels and the intestine for access in laparoscopy. METHODS: For 10 patients scheduled to undergo laparoscopic cholecystectomy, the operation started with the computed tomography (CT) scan. After orotracheal intubation, a CT scan of the umbilical region was performed. After a supraumbilical incision, the fascia was freed and elevated with stay sutures. During maximal elevation, a second CT scan was performed. Distances to the intestinal (small bowel) and retroperitoneal structures (iliac artery, vena cava) were measured. Intraabdominal pressure was measured with a transcystic balloon manometer before (a) and after (b) elevation of the fascia, after insertion of the Veress needle (c), and after completion of the insufflations (d). RESULTS: Lifting of the fascia increased the distance between the fascia and the intestinal structures in the patients with no prior abdominal surgery (mean distance, 1.92 cm; range, 0.87-2.67 cm) and the distance between the fascia and the retroperitoneal vessels (mean distance, 7.83 cm; range, 3-11 cm). The median intraabdominal pressures in terms of cm H(2)O were 5.4 for a, 1.1 for b, 1.1 for c, and 12. 5 for d. CONCLUSION: Elevation of the fascia before the first entrance to the abdominal cavity for laparoscopy may increase safety due to a significant enlargement of distance between the fascia and the retroperitoneal structures.

NOTES--A new era?

BACKGROUND/AIMS: After the first reports from the United States and India of accessing the peritoneal cavity via a transgastric route and performing operations without any abdominal incision, surgeons, as well as gastroenterologists worldwide, became interested in developing research projects in this topic. We evaluated the first papers and reports about the research and new techniques to focus on the possible advantages of NOTES (Natural Orifice Translumenal Endoscopic Surgery). METHODOLOGY: The literature was screened in the time period January 2000 to June 2007 for research and development in NOTES and several reports and abstracts from the year 2007 (January to June) were reviewed. RESULTS: Several research groups in the U.S. and Europe have published in this field of research and their advances and results are discussed. CONCLUSIONS: NOTES is a new era in surgery, but it will only partially replace laparoscopy as it will not be suitable for all patients and indications. To make NOTES suitable in daily surgical practice, it will take several years of research. NOTES research will boost the development of new endoscopes and instruments also helping to advance laparoscopic techniques.