Transfundal insertion of a Veress needle in laparoscopy of obese subjects: a practical alternative

Markku Santala1, Ilkka Järvelä and Antti Kauppila

Department of Obstetrics and Gynaecology, University of Oulu, FIN-90220 Oulu, Finland


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Because induction of artificial pneumoperitoneum through the infra-umbilical route is associated with complications in laparoscopic procedures, especially in obese patients, we performed a prospective randomized study comparing the conventional infra-umbilical route with a transfundal route, in which the Veress needle is inserted into the peritoneal cavity through the uterine fundus. One hundred obese subjects (body mass index >=25 kg/m2) scheduled for laparoscopic sterilization were randomized into two groups. In the infra-umbilical group pneumoperitoneum was achieved at a ratio (punctures/pneumoperitoneum) of 56/49 (1.14). There was one failure in this group. In the transfundal group the ratio was 53/51 (1.04). There was no clinically significant bleeding in either of the groups; nor were there any major complications. One subject in whom the infra-umbilical route failed was moved to the transfundal group. This subject also underwent dilatation and curettage at the time of laparoscopy. Postoperatively she contracted chlamydial pelvic inflammatory disease. No other infections were detected postoperatively in either of the groups. In conclusion, the transfundal route of inducing artificial pneumoperitoneum proved to be easy, safe and effective.

Key words: laparoscopic/pneumoperitoneum/sterilization


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
In a recent study, the mortality rate associated with laparoscopic procedures was 3.33 per 100000 laparoscopies and the overall complication rate was 4.64 per 1000 laparoscopies (Chapron et al., 1998Go). One-third of the complications were secondary to creation of the pneumoperitoneum or installation of the trocars (Chapron et al., 1998Go). Almost half of the complications taking place during the set-up phase were vascular injuries and ~15% of them secondary to insertion of the infra-umbilical Veress needle during the creation of artificial pneumoperitoneum (Chapron et al., 1997bGo). To avoid the risks associated with the infra-umbilical route, there have been trials where artificial pneumoperitoneum has been created by inserting the Veress needle through the uterine fundus into the peritoneal cavity (Sanders and Filshie, 1974Go; Morgan, 1979Go; Wolfe and Pasic, 1990Go; Trivedi and MacLean, 1994Go), but no randomized studies comparing these two routes have been published.

To evaluate the safety of the transfundal technique in relation to the infra-umbilical route, we performed a randomized prospective study in obese subjects scheduled for laparoscopic sterilization. The main goals were to assess the efficacy and safety of the transfundal route when inducing artificial pneumoperitoneum.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
One hundred consecutive women with a body mass index (BMI) of >=25 kg/m2 attending our clinic for sterilization were enrolled into the trial. Women with a history of severe pelvic inflammatory disease, adhesions obliterating the cul-de-sac, uterine fibroids or a uterine cavity of >10 cm in length were excluded from the study. For allocation to the study groups we used sealed envelopes prepared in blocks of 20. The two groups were similar in age, BMI, height, weight and uterine size (Table IGo).


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Table I. Baseline characteristics of the subjects (median and range)
 
The Ethics Committee of the University of Oulu approved the study protocol. Each woman gave informed written consent before allocation to either of the groups.

A single experienced surgeon (M.S.) performed all operations, which were carried out under general anaesthesia. The transfundal operation was performed with the subject in a modified lithotomy position. After vaginal cleansing the anterior lip of the cervix was grasped with a tenaculum and the Veress needle was inserted first into the cavity of the strongly anteverted uterus and then pushed through the fundal uterine wall in the midline of the uterus. The snap of the spring-loaded mechanism of the Veress needle and the low pressure of the abdominal cavity (<10 mmHg) immediately indicated that the tip of the needle was in the abdominal cavity. In the infra-umbilical group, the Veress needle was inserted at the lower border of the fossa umbilicus, perpendicularly through the abdominal wall. If a second attempt was unsuccessful in either group, the subject was transferred to the other group.

The laparoscopic sterilization technique was similar in both groups: a 10 mm laparoscope was inserted through a 1.5 cm infra-umbilical incision and the applicator through the lower abdomen on the right side. The subjects left the hospital on the afternoon of the day of surgery. Prophylactic antibiotics were not used.


    Results
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The median time from the start of the procedure to the last abdominal suture was 13 min in both groups (Table IIGo). In the infra-umbilical Veress needle insertion group, the procedure failed in one subject; none in the other group. The height of the subject in whom the procedure failed was 172 cm, weight 81 kg, BMI 27.4 kg/m2 and uterine cavity length 8.5 cm. In her case, the transfundal procedure was successful. On the 11th postoperative day, she suffered from endometritis. Chlamydia culture was positive. No other postoperative infection developed.


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Table II. Operating time, number of punctures, success rate and volume of blood loss
 
Uterine bleeding was minimal. It was >=5 ml in only three cases in the transfundal insertion group (Table IIGo).

Laparoscopy revealed moderate or severe adhesions between the posterior cervix and adnexae in two subjects, one in each group.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
According to our results, the transfundal route is at least as effective as the conventional infra-umbilical route, which is in accordance with previous observations in non-randomized studies (Sanders and Filshie, 1974Go; Morgan, 1979Go; Wolfe and Pasic, 1990Go; Trivedi and MacLean, 1994Go). Because there was one conversion from the infra-umbilical group to the transfundal group, the success rate (number of punctures/artificial pneumoperitoneum) was 1.14 in the infra-umbilical group and 1.04 in the transfundal group. Fewer punctures during the set-up phase suggest that the transfundal method could be even safer than the conventional method. The transfundal method did not increase the operation time, which also partly reflects the convenience of this method.

Unexpected perforation of the uterus during gynaecological procedures is an unpleasant complication which increases local bleeding and may increase the risk of infection. Transfundal perforation performed with a Veress needle in the present study was not associated with clinically significant bleeding. All the punctures were aimed at the midline of the uterine fundus, which has a thick myometrium with a good tamponade capacity in comparison, for example, with the cornual region. The diameter of the needle used was 2 mm, which also partly explains the lack of problems from bleeding.

Only one postoperative infection occurred. Endometritis manifested itself 11 days after operation in a Chlamydia-positive woman. Screening for Chlamydia in subjects scheduled for laparoscopic procedures is not included in routine preoperative laboratory tests in our hospital.

No major complications in the pelvic organs occurred in either group. There was no reason to expect a high incidence of complications to occur in the light of previous studies (Chapron et al., 1998Go), and because the total number of patients was only 100 in the present study. Nevertheless, according to our results it appears that the transfundal route is not associated with an increase in the rate of pelvic organ complications when compared with the infra-umbilical technique. It is essential, however, to perforate the fundus when the uterus is strongly anteverted, in which case the needle is targeted towards the anterior abdominal wall instead of vulnerable pelvic organs.

Contra-indications for the transfundal route were a history of severe pelvic inflammatory disease, and adhesions obliterating the cul-de-sac. In these cases there is an increased risk of bowel perforation. Infertility has also been suggested to be a contraindication as regards this method (Morgan, 1979Go; Wolfe and Pasic, 1990Go). Theoretically, there may also be an increased risk of endometriosis and adenomyosis associated with this method (Trivedi and MacLean, 1994Go).

Because the incidence of laparoscopic complications is higher among inexperienced operators (Chapron et al., 1997aGo,bGo, 1998Go), the transfundal route in inducing artificial pneumoperitoneum could be the method to consider during the training period of an inexperienced laparoscopist. The results of randomized and larger studies will later show whether the transfundal route could be the method of choice in inducing a safe artificial pneumoperitoneum in women with no known contra-indications for transfundal puncture undergoing gynaecological laparoscopic procedures.

To summarize, the transfundal route of Veress needle insertion is as effective as the conventional infra-umbilical route in inducing artificial pneumoperitoneum, and it is not associated with an increased risk of haemorrhage, infections or pelvic organ injuries.


    Notes
 
1 To whom correspondence should be addressed Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Chapron, C., Devroey, P., Dubuisson, J.B. et al. (1997a) ESHRE guidelines for training, accreditation and monitoring in gynaecological endoscopy. European Society for Human Reproduction and Embryology. Committee of Special Interest Group on Reproductive Surgery. Hum. Reprod., 12, 867–868.[Free Full Text]

Chapron, C.M., Pierre, F., Lacroix, S. et al. (1997b) Major vascular injuries during gynecologic laparoscopy [see comments]. J. Am. Coll. Surgeons, 185, 461–465.[ISI][Medline]

Chapron, C., Querleu, D., Bruhat, M.A. et al. (1998) Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 2966 cases. Hum. Reprod., 13, 867–872.[Abstract]

Morgan, H.R. (1979) Laparoscopy: induction of pneumoperitoneum via transfundal puncture. Obstet. Gynecol., 54, 260–261.[Abstract]

Sanders, R.R. and Filshie, G.M. (1974) Transfundal induction of pneumoperitoneum prior to laparoscopy. J. Obstet. Gynaecol. Br. Cmwlth, 81, 829–830.

Trivedi, A.N. and MacLean, N.E. (1994) Transuterine insertion of Verres needle for gynaecological laparoscopy at Southland Hospital [see comments]. NZ Med. J., 107, 316–317.

Wolfe, W.M. and Pasic, R. (1990) Transuterine insertion of Veress needle in laparoscopy [see comments]. Obstet. Gynecol., 75, 456–457.[Abstract]

Submitted on April 6, 1999; accepted on June 17, 1999.





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