|Year : 2012 | Volume
| Issue : 3 | Page : 85-89
Veress needle insertion through left lower intercostal space for creating pneumoperitoneum: Experience with 75 cases
Department of Surgery, Guru Teg Bahadur Hospital and University College of Medical Sciences, Dilshad Garden, Delhi, India
|Date of Submission||04-Mar-2011|
|Date of Acceptance||09-Jun-2011|
|Date of Web Publication||29-Jun-2012|
B-901, Pawittra Apartments, Vasundhara Encalve, Delhi- 110 096
Source of Support: None, Conflict of Interest: None
Context: Veress needle insertion (VNI) at sub-umbilical fold (SUF) midline is associated with serious intra-abdominal injuries. Aim: The aim of this study has been to evaluate the safety and efficacy of lower left intercostal space (LICS) for VNI. Settings and Design: This prospective observational study was conducted in three parts in Surgery-II, Department of Surgery, GTBH-UCMS, Delhi. Materials and Methods : In part one, skin fold thickness (SFT) was measured in 32 patients at SUF, LICS, right iliac fossa (RIF) and Palmer's point. As part two, in these patients, VNI was carried out from LICS under laparoscopic guidance. As part three, same technique of VNI was employed in 43 patients with suspected intra-abdominal adhesions undergoing laparoscopy for various reasons. Observations were made regarding ease of insertion, attempts needed for successful entry, loudness or clarity of give-way feeling of Veress needle, intra-abdominal bleeding at point of emergence of Veress needle, hemopneumothorax, bowel or vascular injury. Statistical Analysis Used: SFT was expressed as mean (SD), and one-way ANOVA followed by Tukey's test were employed to find the statistical significance. Results: SFT at LICS was significantly less as compared to SUF and Palmer's point. VNI at LICS was easy to carry out; it could be successfully done in first attempt in all patients, and was associated with very clear and loud give-way feeling. There were no instances of intra-abdominal bleeding at point of emergence of Veress needle, hemopneumothorax, bowel or vascular injury. Conclusions: VNI at LICS as described here is safe and effective.
Keywords: Abdominal entry, laparoscopy, veress needle insertion
|How to cite this article:|
Kumar S. Veress needle insertion through left lower intercostal space for creating pneumoperitoneum: Experience with 75 cases. J Min Access Surg 2012;8:85-9
|How to cite this URL:|
Kumar S. Veress needle insertion through left lower intercostal space for creating pneumoperitoneum: Experience with 75 cases. J Min Access Surg [serial online] 2012 [cited 2020 Sep 20];8:85-9. Available from: http://www.journalofmas.com/text.asp?2012/8/3/85/97590
| ¤ Introduction|| |
Safe and successful intra-abdominal entry is a prerequisite for any laparoscopic procedure. There are many techniques for abdominal entry but most surgeons gain it by Veress needle insertion (VNI) through sub-umbilical fold (SUF) in midline. Although generally safe, this technique may be associated with life-threatening complications such as bowel, intra-abdominal vessels and urinary bladder injuries. This is especially true of patients with suspected intra-abdominal adhesions and obesity. 
Therefore, it is important for the surgeon to be well versed with alternate techniques of intra-abdominal access such as direct trocar insertion (DTI), VNI through Palmer's point, right iliac fossa (RIF) and uterine fundus (in females). DTI, probably safe in very experienced hands, itself may lead to very severe intra-abdominal injuries, and hence finds little favours. Unsuspected intra-abdominal adhesions, especially due to tuberculosis, are not uncommon in tropical countries, and may virtually rule out the use of Palmer's point and RIF for VNI.
Hence, in order to find another safe site for VNI, the author measured the skin fold thickness (SFT) at various potential sites for VNI, initially inserted the Veress needle through left lower intercostal space (LICS) under telescopic guidance to master the skill and later used this technique in indicated patients to study the safety profile of VNI through LICS. The results of the same are discussed herein.
| ¤ Materials and Methods|| |
This prospective observational study was conducted in one of the surgical units in Department of Surgery at Guru Teg Bahadur Hospital affiliated to University College of Medical Sciences, Delhi since May 2005 following ethical clearance from the hospital ethical committee. There are three components of this study.
As first component, SFT was measured at SUF, RIF, Palmer's point and LICS using Vernier calliper in 32 consecutive and unselected, otherwise healthy female patients undergoing laparoscopic cholecystectomy. The measurements were taken under general anaesthesia. The values were tabulated and expressed here as mean (SD).
Subsequently, as second component, in this group of 32 patients, an NG tube was inserted and then the author created pneumoperitoneum using standard percutaneous VNI technique through an incision in SUF. Thereafter, a 12-mm trocar was inserted at umbilicus to house 30° telescope, and preliminary examination of the peritoneal cavity was conducted especially to look for any intra-abdominal adhesions in the region of the left sub-costal space. Thereafter, the author inserted Veress needle under laparoscopic view through a 2-mm transverse incision in lower most LICS while carefully adhering to the technical details as mentioned below (see section 'technique of VNI through LICS' below). This exercise was undertaken to master the skill of VNI from LICS, and patient's written and informed consent had been taken for the same. At this time, observations regarding ease of insertion, number of attempts required to position the needle in the peritoneal cavity, intra-abdominal bleed from the site of VNI, hemopneumothorax and position of the needle with respect to transverse colon were made. Clinical examination was relied upon to look for hemopneumothorax.
After gaining this initial experience, and finally as a third component, VNI was performed blindly through LICS to create pneumoperitoneum as the method of choice in selected 43 cases under GA after written informed consent. Once again, the technical details as mentioned below (see section 'technique of VNI through LICS' below) were followed strictly. The indications for laparoscopy in these patients were: gallstone with previous abdominal surgery, mostly LSCS or hysterectomy (n=14), diagnostic lap for undiagnosed abdominal pain (n=18), laparoscopic right hemicolectomy for abdominal tuberculosis (n=05), laparoscopic cystogastrostomy for pancreatic pseudocyst (n=02), cystic duct stone following previous laparoscopic cholecystectomy (n=01), truncal vagotomy and gastrojejunostomy for recurrent benign duodenal ulcer following previous laparotomy for duodenal perforation (n=01), laparoscopic biopsy from liver and gallbladder mass following open upper abdominal surgery (01) and laparoscopic choledochotomy for common bile duct (CBD) stones following previous laparoscopic cholecystectomy (n=01). Standard saline drop test was employed to test for correct placement of the Veress needle. Clinical observations regarding ease of insertion, number of attempts made to place Veress needle in the peritoneal cavity and hemopneumothorax were made immediately after VNI, and observations concerning intra-abdominal bleed from parities and intra-abdominal viscera injury were made after inserting the laparoscope from the umbilical port.
After creating pneumoperitoeum, a 5.5-mm port was inserted at a site possibly free of adhesions. This was, of course, a clinical decision based on the experience of the author and the site of adhesions or bowel pathology suspected in the above 43 patients. Through this 5.5-mm trocar, a 5-mm laparoscope was inserted and observations regarding intra-abdominal bleed from LICS VNI point and bowel injury from Veress needle were made. Also, the peritoneal cavity was inspected to look for adhesions due to previous surgery or disease as this was the primary reason for creating pneumoperitoneum from an alternate route. If present, the adhesions were broken down with the help of other trocar and endo-scissors. Thereafter, the indicated surgical procedure was completed laparoscopically in all these patients.
After surgical procedure, the patients were monitored and treated in post-operative wards as per their needs, and discharged as per their progress.
Technique of Veress needle insertion through left intercostal space
Stomach was decompressed by a wide bore NG tube. Widest and lower most LICS was palpated and a 2-mm transverse incision was made in the skin and subcutaneous tissue, generally between the midclavicular and the anterior axillary lines [Figure 1]. Holding the Veress needle in the right hand (the author is right handed) by the 'pen-grip', it was gently but firmly pushed inside the abdomen towards the umbilicus while keeping the needle tip over the superior aspect of the lower most rib [Figure 1]. Force of insertion was controlled as soon as a loud click was heard and a clear 'give-way' was appreciated. Thereafter, a saline test was performed and insufflations begun if positive. Masking of liver dullness, too, confirmed the intra-peritoneal position of the Veress needle. Once successful insufflation began, the needle was directed towards the umbilicus for about 3 to 4 cm [Figure 2] while remaining just beneath the abdominal wall; it must be specified that the needle tip could be felt sub-costally in average built patients.
|Figure 1: Outside view showing Veress needle insertion through LICS just lateral to midclavicular line|
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|Figure 2: Veress needle lying safely in peritoneal cavity after insertion through LICS|
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SFT was expressed as mean (SD) mm. All four sites were compared by one-way ANOVA (F-test) followed by multiple comparisons by Tukey's test, with significance taken at 5%.
| ¤ Results|| |
Mean (±SD) SFT (mm) at four sites on trunk in 32 patients and their comparison has been given in [Table 1]. It was thinnest at LICS and thickest at Palmer's point. SFT at LICS was significantly less as compared to SFT at SUF as well as Palmer's point, P value being equal to 0.035 and 0.018, respectively.
During the second part of the study, it was found that VNI was easy and associated with very pronounced give-way feeling in all 32 patients. Veress needle could be placed intra-peritoneally in single attempt in all 32 patients. There were no instances of bleeding from inside of the lower chest wall or hemopneumothorax. Transverse colon was found to be low in relation to the point of entry at LICS.
During third component of the study, it was found that Veress needle was easy to inset at LICS and was associated with very pronounced 'give-way' feeling in all 43 patients. Additionally, Veress needle could be placed intra-peritoneally in single attempt in all 43 patients. There were no instances of hemopneumothorax, bowel injury or intra-abdominal bleed from parities at Veress needle entry point.
| ¤ Discussion|| |
Laparoscopy is now a very common procedure, and complications associated with it are often related to intra-abdominal entry. These complications could be life-threatening or less serious. Life-threatening complications include injury to bowel, urinary bladder and major abdominal vessels. Less serious complications of concern include injury to abdominal wall vessels, sub-cutaneous emphysema and extra-peritoneal insufflation.
There are several methods of intra-abdominal entry. These include classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion (DTI) without prior pneumoperitoneum, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. There is no advantage of one over the other; and therefore, no clear consensus concerning the optimal method of entry exists. 
Open entry technique has not been shown to be superior to other methods of gaining access to the peritoneal cavity,  although the authors of a non-randomized trial find open method to be safe as well as easy.  In a recent and one of the largest trials comparing periumbilical VNI and open method for creating pneumoperitoneum, no difference in complication rate was found. 
DTI may be used as a safe alternative to VNI; it is said to avoid insufflations related complications such as gas-embolism, extraperitoneal insufflations and failed entry while leading to faster pneumoperitoneum. , Visual entry cannula system represents an advantage over the traditional trocars as it allows clear visual entry. These can minimise size of the entry wound; however, evidence is lacking concerning its superiority over the traditional trocars, especially in avoiding visceral and vascular injuries. 
VNI followed by CO 2 insufflation and trocar placement remains the most common method. VNI at Palmer's point needs to be considered in patients suspected or known periumbilical adhesions or umbilical/par umbilical hernia or after three failed attempts of VNI through SUF midline.  Intra-abdominal access via VNI at Palmer's point has been shown to be safe and effective.  Further, Palmer's point and SUF in the midline are equally safe and effective for VNI. 
SUF in midline is the most common site for VNI. Elevation of the anterior abdominal wall at the time of VNI does not prevent visceral or vascular injury, and, hence is not recommended.  The angle of VNI must be according to the BMI of the patient, 45 degrees in non-obese patients and 90 degrees in obese patients.  However, a recent and comprehensive audit reveals that VNI at SUF in midline 'poses serious risk to the life of patients', thereby justifying further studies to find alternate sites for VNI. 
The author believed that the thickness of the skin fold may be an important factor in deciding the success of the VNI at alternate site. Thus, in order to look for alternate safe site for VNI, the author conducted this study in three parts.
Measurement of SFT at various points over the trunk, undertaken as the first component of the study revealed that it was least at LICS and maximum at SUF. Therefore, in the first go it appeared that VNI at LICS should be easy and equally safe. This was confirmed, during second component of this study, by successful VNI in first attempt in all patients, very pronounced and clear 'give-way' feeling during VNI, and absence of complications such as bleeding at entry point in the abdomen, bowel injury and hemopneumothorax. Later on, as the third component of the study, VNI through LICS was once again confirmed to be a safe and good option in cases with suspected intra-abdominal adhesions.
Since, it was not practical to take the chest X-ray in an anaesthetized patient in the set-up where the author works, hemopneumothorax was ruled out clinically by continuous observation of respiratory parameters throughout the surgery. Surgeons skilled in use of USG for detecting hemopneumothorax, as in trauma, may use the USG to its advantage in detecting hemopneumothorax in anesthetized patients after VNI through LICS.
While using the LICS for VNI it is advised that the stomach should be decompressed by means of an orogastric tube. Furthermore, once a loud click is heard and clear 'give-way' feeling is felt, the needle tip should be directed towards the umbilicus just underneath the abdominal wall. In fact, in thin to moderately built patients the needle can be felt percutaneously as it emerges from the under surface of the left costal margin. On the other hand, Veress needle cannot be felt (because of deeper direction of insertion) in any other method of VNI. The intercostal spaces are crowded medial to the mid-clavicular line; these get wider lateral to the mid-clavicular line. Thus, the site of insertion should be carefully chosen in the lower most LICS between mid-clavicular and anterior axillary line. Choosing entry point further lateral than the anterior axillary line will put the splenic flexure of the colon at risk of perforation, and hence is not advised. In author's opinion, it is mandatory to take care of these technical details to be successful and safe with this technique of VNI at LICS.
One of the drawbacks of VNI through LICS may be injury to the stomach. Although there were no injuries to gut, the author feels that such injuries to stomach are easy to recognise and repair, as compared to the small and large bowel injuries. This offers additional advantage of the VNI through LICS. Further, decompressing the stomach by orogastric tube before VNI and controlled direction of needle towards the umbilicus just beneath the abdominal wall after hearing a loud click and appreciating a clear 'give-way' feeling can help prevent the gut injuries.
Risk of hemopneumothorax is theoretical; pleural reflections are generally high up, while the author is recommending the use of lowermost LICS for VNI with tip directed towards the umbilicus. Furthermore, staying on superior margin the lower rib avoids injury to the intercostal vessels.
The author also made unrecorded observations between VNI through LICS and Palmer's point, and it was seen that VNI through LICS was easier and associated with louder and clearer give-way feeling as compared to VNI through Palmer's point.
To conclude, VNI through LICS is a safe and technically sound alternative to the standard SUF in midline and Palmer's point entry. It should be used in patients suspected to have intra-abdominal adhesions, umbilical/paraumbilical hernia, and obesity and after 2-3 failed attempts at SUF midline. The lowermost and the widest LICS, between the mid-clavicular and the anterior axillary lines, should be used. The needle tip should be directed towards the umbilicus. Associated with a very pronounced 'give-way feeling', the technique is easy to master. Decompression of the stomach by orogastric tube is mandatory before using this technique.
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[Figure 1], [Figure 2]
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