CORRESPONDENCE

A modified technique of Veress needle insertion in laparoscopic surgery

Closed insertion of the Veress needle and first trocar can result in severe vascular and visceral injuries.¹ Consequently there has been an increased interest in the use of open insertion techniques in laparoscopic surgery. Studies have shown that open establishment of pneumoperitoneum is safer than the closed method.^1,2 Despite these findings many surgeons still use Veress needle insufflation and blind first trocar insertion because they feel that the closed technique is faster, requires a smaller incision and is not associated with gas leakage.2 For those using a closed technique we suggest a slight modification of the veress needle insertion, which we have found useful and may be safer than the standard technique.

Most closed techniques involve making a small sub umbilical incision, elevating the abdominal wall by hand or with clips, the Veress needle is then held like a dart and introduced vertically downward until it is felt to enter the peritoneal cavity. We describe a slight modification to this general technique of Veress needle insertion that can be performed by a single operator. Having made a 1cm incision just below the umbilicus the superior edge of this incision is grasped and elevated with a Littlewoods tissue forceps held in the left hand. Traction is applied vertically upwards thus the base of the umbilicus is tented upward and away from intra peritoneal structures. The base of the umbilicus is a fibrous structure and therefore usually avascular. With the Veress needle in our right hand we pass it through the incision along the inferior edge of the umbilicus aiming to enter the peritoneal cavity via the base of the umbilicus. Using this technique, we can surface. A search of the literature revealed that Genovese³ described a similar technique whose main difference involved dissecting down to the fascia and then grasping the umbilical raphe prior to insertion of the Veress needle. It is our opinion that our modified technique is relatively simple and safe.

REFERENCES

1. Nuzzo G, Giuliante F, Tebala G D, Vellone M, Cavicchioni C. Routine use of open technique in laparoscopic operations. J Am Coll Surg 1998; 184: 58-62
2. Bonjer H J, Hazebroek E J, Kazemier, Giuffrida M C, Meijer W S, Lange J F.Open versus closed establishment of pneumoperitoneum in laparoscopic sugery. Br J Surg 1997; 84: 599-602
3. Genovese ML. Modification of Veress needle insertion. Surgical Laparoscopy, Endoscopy, & Percutaneous Techniques 1998; 8: 160-1

P.S. KANG, X. ESCOFET and A.P. WETHERALL 
Department of Surgery, Kidderminster District General Hospital, West Midlands, U.K.

Methods for achieving pneumoperitoneum at laparoscopy 
1999; 44(4):324-7

Sir: Sengupta and Paterson-Brown are to be complimented on their report comparing open and 'blind' techniques to achieve pneumoperitoneum.

In Australia, considerable adverse publicity has attended the handful of complications caused by the Verres needle, while reported problems with the Hasson technique have received scant attention. Non-anecdotal, unbiased and convincing scientific data to support one or other method are, as yet, to be published.

We have been using the 'blind' technique with the Verres needle since 1984, and have a combined total of approximately 14 000 cases without a single serious complication.

We stress that the inherent dangers of the Verres procedure can only be minimised by scrupulous attention to detail, and our protocol is as follows:

• Always use the left subcostal approach unless there is history of splenectomy or blunt abdominal trauma to that quadrant where the parietal peritoneum is firmly adherent to the posterior rectus fascia, in comparison with the umbilical region. Traditional placement of the Verres needle in the lower abdomen is a concern because of the higher incidence of previous laparotomy wounds in this area and the proximity of major abdominal blood vessels.
• Use the PAJUNK disposable needle (Medizintechnologie,Germany) with the reusable internal spring-loaded trochar or the single use Verres needle.
• Note the three distinct 'clicks' of the trochar as the three fascial planes of the abdominal wall are penetrated. In extremely obese subjects, safety can be enhanced by dissection of the fat beneath the skin incision to the level of the external rectus sheath, so the Verres needle can be more accurately placed in to the abdominal cavity.
• Check the intra-peritoneal pressure/gas flow rate with an initial setting of 12 mm Hg/1 litre per min flow. If the tip of the needle is in the peritoneal cavity there should be a low I/P pressure and high flow rate. If there is any doubt about the position of the needle, it is removed and the whole procedure repeated. Once the needle position is assured, the gas flow is increased to the maximum. The 12 mm trochar is inserted once the intraperitoneal pressure has reached 12 mm Hg.
• One common, but trivial, complication is insufflation of gas bubbles in to the greater omentum. These diffuse spontaneously within 5-10 minutes, but if they are troublesome, they can be removed by reinserting the needle without the gas supply attached.

This technique has the advantage of speed and the absence of any major vascular structures in the left upper abdominal quadrant, and although there is a theoretical risk to the transverse colon or the greater curve of the stomach, even if the anaesthetist has inadvertently inflated the latter we have not encountered any problems.

We disagree with Sengupta and Paterson-Brown when they suggest that the open method, "...is often quicker than the closed method, particularly in obese patient" because, in our experience, it is with obese patients what the Verres technique offers the greatest benefit.

R.S. ARNOT AND T. WILSON 
Inverell, Australia

Authors' reply:

We agree that there has been considerable adverse publicity associated with the complications of Verres needle laparoscopy, but would point out that the reason there has not been much published data on the open laparoscopic technique is that in general it is inherently safer. However, as the authors correctly point out, there have been no randomised controlled trials comparing these two techniques and as the incidence of complications following Verres needle laparoscopy are small it is unlikely that a trial comparing the two would ever be carried out.

We also agree that in the most experienced hands blind laparoscopy remains a relatively safe procedure but the problem is that laparoscopy is not always carried out by highly experienced and trained surgeons and, as such, the open technique is more likely to be safer. The purpose of our study, however, was not to make any direct comparison between the two techniques, but simply to try and identify what techniques the surgeons in Scotland were using. We have identified that the General Surgeons predominantly use open laparoscopy compared with the Gynaecologists who invariably use the closed, 'blind' technique. The reasons behind this are of course conjecture, but it remains an interesting observation.

F. SENGUPTA and S. PATERSON-BROWN 
The Royal Infirmary of Edinburgh

Renal cell carcinoma: incidental detection and pathological staging 
2000; 45(5):291-295

We read with interest the report by Siow et al (2000) on the pathological staging of incidentally detected renal cell carcinomas. We commend their findings, which are consistent with the results of an audit recently undertaken in our unit.

Between 1991 and 1998, 100 cases of renal cell carcinoma were recorded. Of these nearly a quarter were originally referred with LUTS and features consistent with bladder outflow obstruction. Upper-tract ultrasonography (undertaken routinely in the investigation of this group of patients) revealed 24 renal cell carcinomas - nearly one quarter of the total number presenting to our department. 67% of these were stage I or II, as compared with 38% of the remainder (P<0.05) who presented by a variety of other modes (haematuria, loin pain, etc.). This finding is reflected in the average size of the tumour which was 5.8 cm in the incidental and 9.2 cm in the symptomatic group, respectively. Four percent of those presenting incidentally were deemed inoperable because of the extent of the disease, as compared with 25% of those who had other modes of presentation.

We believe that routine ultrasonography in men presenting with LUTS affords a significant opportunity to screen for upper tract malignancy although its principle intention is to identify hydronephrosis. Given the earlier stage at which these tumours appear to have presented they represent a good prognostic group. In our study, like the authors, we have demonstrated improved survival rates in the 'incidentally' presenting cohort of patients (mean 30 months follow-up).

T. LANE 
London, U.K.

Cardiothoracic trainees and junior doctors’ working hours

Sir: In the past couple of years many changes and implementations have taken place in the junior doctor working hours. With the new banding system and changes to be enforced in December 2000, matters are moving at a considerable pace. While many changes are for the betterment of the surgical trainees, there are a few trainees who do not fit well into these changes and are adversly affected. One such group is the career SHOs in cardiothoracic surgery.

The SHOs in cardiothoracic surgery belong to two groups, one group consists of the Basic Surgical Trainee who spent time in cardiothoracic surgery as a part of their Basic Surgical Rotation and the other are those who are training towards a career in cardiothoracic surgery (SHO IIIs in Scotland and senior SHOs in England). The number in the latter group is significantly lower than before due to Calman changes when many jobs were integrated into surgical rotations.

The integration of cardiothoracic surgery as a part of Basic Surgical Training is excellent because a Cardiothoracic Unit provides the trainee with all the facets of Intensive Care (applied physiology and critical care, hands on experience in invasive monitoring and advanced life support). The 6 months they spend in cardiothoracic surgery is very useful in terms of preparation for the examination but the hands-on surgical exposure is limited

.The trainees will train in harvesting conduits and opening and closing the chest but this is no more than minimal practical experience of cardiothoracic surgery. If the trainee wishes to pursue a career in cardiothoracic surgery there are very few training posts in the where he can further his operative skills and ITU expertise. Everyone involved in cardiothoracic surgery knows that the entry criteria for a registrar post is 12 months of cardiothoracic experience, ability to open and close chests and harvest the internal mammary artery. Where is the trainee to find a post to gain this experience, as there is scarcity of such posts? Also, it is hard for a Cardiothoracic Trainee to start at 9.00 a.m. and finish at 5.00 p.m. and at the same time gain good clinical experience. Cardiothoracic surgery is a specialty where the working day commences at 8.00 a.m. and the finish is unpredictable due, not infrequently, to patient instability.

The Higher Surgical Trainees get waived by the English Clause, which allows them to work longer hours but it's the SHO who pays the price because they are not covered by the clause. Some trusts try to tackle the issue of working hours by changing to a full shift system but that will be detrimental to cardiothoracic training. Cardiothoracic surgery is a field where things happen very fast and in a progressive fashion which needs a continuous follow-up.

Cardiothoracic is a long process which needs dedication and sincerity (some senior consultants even today mention that they did 1in1 and1in 2 rotas) But the present scenario does not enable those who want to do that due to the junior doctor hours. This is a serious issue, which needs addressing. Changing over to full shift system is not a solution. Moreover senior SHO posts for trainees interested in a career in Cardiothoracic surgery should be left alone and more such posts should be created for those who wish to pursue a career in this field.

S. RATHINAM Walsgrave 
Hospital, Coventry, U.K.

©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.